Adapting Health Technology Assessment agency standards for surrogate outcomes in early stage cancer trials: what needs to happen?

INTRODUCTION

An avalanche of early stage cancer clinical trials is coming. The majority of these solely use surrogate outcomes that have not been validated against a target outcome of interest (e.g. overall survival). Current HTA guidance on surrogate outcome validation are not methodologically or practically conducive to this scenario.

AREAS COVERED

We provide a high-level overview of methods, approaches, and conceptual thinking for making better use of limited evidence within early stage cancer HTA submissions. We outline regulatory and HTA issues and emphasize how evidence transitions from one to another, what major gaps currently exist, and how these may be bridged. We summarize current methodologies and practices, their pros and cons. We outline how complementary measurements strengthen evaluations and address fallacies and biases of conventional statistical methods for surrogate outcomes validation. The value of real-world data to support some of the necessary validity components is discussed. Lastly, we address the importance of the patient voice for better understanding which surrogate outcomes may appropriately inform HTA.

EXPERT OPINION

Conventional surrogate outcome validation represents a fraught and sub-optimal framework for HTA purposes, particularly for early stage cancer. Tools for optimizing use of limited evidence exist. Education of stakeholders is highly needed.

Radiography lecturers' understanding of a socially responsive curriculum

INTRODUCTION

In health professions education (HPE), focus is placed on developing clinically competent practitioners who can function within their professional scope in a broad range of health care contexts. In this study, the authors investigated diagnostic radiography lecturers' understanding of how students become socially responsive. The concept of 'critical consciousness' was explored as an intervention of being a transformer in the local environment. This places focus on learning and teaching that aims to develop radiography graduates who are critically conscious, such that they can take up the challenges of healthcare in their environment, in addition to being clinically competent in their field. The study under discussion therefore sought to find out how radiography lecturers understand a socially responsive curriculum at a University of Technology in the South African context.

METHOD

A qualitative, exploratory design was used where curriculum documents were reviewed and from which stimulus points were identified for a semi-structured focus group interview with radiography lecturers followed by five individual interviews. All interviews were audio-recorded, transcribed, coded and analysed through a process of thematic analysis.

RESULTS

Four dominant themes emerged from the analysis, namely i) diverse understandings of critical consciousness, ii) becoming a reflective practitioner, iii) a need for curriculum transformation and iv) emerging pedagogies.

CONCLUSION

Critical reflection by both the radiography students and lecturers is key to developing social awareness and critical consciousness which could drive critical motivation and critical action to effect social change. It is recommended that the current curriculum should be reviewed and transformed to include constructive reflective practice.

IMPLICATIONS FOR PRACTICE

Dedicated time should be scheduled, in the curriculum, to allow students and lecturers to engage in meaningful constructive reflection to enhance socially responsive practice.

O50: DEVELOPMENT OF A PATIENT-DERIVED TUMOUR ORGANOIDS FROM METASTATIC BREAST CANCER FOR ASSESSMENT OF NOVEL CLINICALLY ACTIONABLE TARGETS

Introduction

Metastatic breast cancer (MBC) is the main source of mortality in breast cancer patients largely due to lack of effective treatments. Our previous results suggest that tumour transcriptional heterogeneity drives therapy resistance and cancer relapse. While traditional in vitro human cancer cell line models have been widely used for disease modelling, they do not faithfully recapitulate the pathophysiology of MBC.

Method

In this study we developed patient-derived tumour organoid cultures from frozen patient-derived (PDX) models of MBC. Using those models we performed preclinical drug screening of investigational and FDA approved therapeutics previously uncovered by us as potentially clinically actionable in MBC.

Result

Our results reveal high heterogeneity in the responses to various targeted therapies among tested MBC organoids, which makes them a valuable tool for studying intra-tumor heterogeneity and drug response. Moreover, drug screening identified a divergent set of the breast to brain metastatic MBC organoids that showed high sensitivity to a new class of tyrosine kinase receptors, RET.

Conclusion

Taken together, our novel MBC models and methodology applied here provides an important modelling tool to assess the contribution of intra-tumour heterogeneity and microenvironment to drug response as they recapitulate the cellular, structural and biochemical complexity previously observed in our genomic characterisation of MBCs. Application of this type of translational research will enhance the development of new targeted precision medicine strategies and prelude stratification for clinical trials. Abbreviations MBC- Metastatic Breast Cancer; PDX- Patient-Derived Xenografts; FDA- Food and Drug Administration; RET- Receptor Tyrosine Kinase

Take-home message

Patient-derived tumour organoid cultures provide an important modelling tool to assess the contribution of intra-tumour heterogeneity and microenvironment to drug response as they recapitulate the cellular, structural and biochemical complexity previously observed in genomic characterisation of metastatic breast cancer.

SURGICAL EDUCATION AND TRAINING

Control of three gastrointestinal illness outbreaks in a British Role 1 facility in Afghanistan: a primary care perspective

INTRODUCTION

In 2019, Camp Qargha (QAA), a British-led multinational military camp in Kabul, had three of the largest outbreaks of gastrointestinal illness (GI) experienced by the British Military since 2003. This paper discusses the incidence, the response of the British-led Role 1 (R1) medical treatment facility, identifies potential causative and exacerbating factors, and explains the control measures initiated.

METHOD

GI in QAA results in local and UK military-wide data collection including in the form of local GI questionnaires, FMed85 forms and EpiNATO returns. The data from these was used to identify trends during and after outbreaks and produce environmental health (EH) and local outbreak reports.

RESULTS

Overall, among the outbreaks 56% of stool samples tested positive for norovirus. In each outbreak incidence peaked within the first 3 days, and hardened multiperson rooms were worst affected. 206 patient presentations occurred during the three outbreaks, 706 working days were lost in isolation, with QAA shut down while in quarantine for 27 days.

DISCUSSION

Significant strain was placed on QAA and the R1. Causative factors may include close interaction with the local national (LN) population, a high population density and accommodation being limited by specific national infrastructure protocols in an operational environment.

CONCLUSION

Early recognition of GI, positive standard operating procedures and good hygiene habits are essential to prevent the spread of GI such as norovirus. An early awareness of LN population illness patterns will allow the R1 and command to be better prepared for outbreaks in the future.

Properties of laser-produced GaAs plasmas measured from highly resolved X-ray line shapes and ratios

The properties of hot, dense plasmas generated by the irradiation of GaAs targets by the Titan laser at Lawrence Livermore National Laboratory were determined by the analysis of high resolution K shell spectra in the 9 keV to 11 keV range. The laser parameters, such as relatively long pulse duration and large focal spot, were chosen to produce a steady-state plasma with minimal edge gradients, and the time-integrated spectra were compared to non-LTE steady state spectrum simulations using the FLYCHK and NOMAD codes. The bulk plasma streaming velocity was measured from the energy shifts of the Ga He-like transitions and Li-like dielectronic satellites. The electron density and the electron energy distribution, both the thermal and the hot non-thermal components, were determined from the spectral line ratios. After accounting for the spectral line broadening contributions, the plasma turbulent motion was measured from the residual line widths. The ionization balance was determined from the ratios of the He-like through F-like spectral features. The detailed comparison of the experimental Ga spectrum and the spectrum simulated by the FLYCHK code indicates two significant discrepancies, the transition energy of a Li-like dielectronic satellite (designated t) and the calculated intensity of a He-like line (x), that should lead to improvements in the kinetics codes used to simulate the X-ray spectra from highly-charged ions.

Differential evolution of peripheral cytokine levels in symptomatic and asymptomatic responses to experimental influenza virus challenge

Exposure to influenza virus triggers a complex cascade of events in the human host. In order to understand more clearly the evolution of this intricate response over time, human volunteers were inoculated with influenza A/Wisconsin/67/2005 (H3N2), and then had serial peripheral blood samples drawn and tested for the presence of 25 major human cytokines. Nine of 17 (53%) inoculated subjects developed symptomatic influenza infection. Individuals who will go on to become symptomatic demonstrate increased circulating levels of interleukin (IL)-6, IL-8, IL-15, monocyte chemotactic protein (MCP)-1 and interferon (IFN) gamma-induced protein (IP)-10 as early as 12-29 h post-inoculation (during the presymptomatic phase), whereas challenged patients who remain asymptomatic do not. Overall, the immunological pathways of leucocyte recruitment, Toll-like receptor (TLR)-signalling, innate anti-viral immunity and fever production are all over-represented in symptomatic individuals very early in disease, but are also dynamic and evolve continuously over time. Comparison with simultaneous peripheral blood genomics demonstrates that some inflammatory mediators (MCP-1, IP-10, IL-15) are being expressed actively in circulating cells, while others (IL-6, IL-8, IFN-α and IFN-γ) are probable effectors produced locally at the site of infection. Interestingly, asymptomatic exposed subjects are not quiescent either immunologically or genomically, but instead exhibit early and persistent down-regulation of important inflammatory mediators in the periphery. The host inflammatory response to influenza infection is variable but robust, and evolves over time. These results offer critical insight into pathways driving influenza-related symptomatology and offer the potential to contribute to early detection and differentiation of infected hosts.

Junctional adhesion molecule-A is co-expressed with HER2 in breast tumors and acts as a novel regulator of HER2 protein degradation and signaling

Junctional adhesion molecule-A (JAM-A) is a membranous cell-cell adhesion protein involved in tight-junction formation in epithelial and endothelial cells. Its overexpression in breast tumors has recently been linked with increased risk of metastasis. We sought to identify if JAM-A overexpression was associated with specific subtypes of breast cancer as defined by the expression of human epidermal growth factor receptor-2 (HER2), estrogen receptor (ER) and progesterone receptor. To this end, JAM-A immunohistochemistry was performed in two breast cancer tissue microarrays. In parallel, cross-talk between JAM-A, HER2 and ER was examined in several breast cell lines, using complementary genetic and pharmacological approaches. High JAM-A expression correlated significantly with HER2 protein expression, ER negativity, lower patient age, high-grade breast cancers, and aggressive luminal B, HER2 and basal subtypes of breast cancer. JAM-A and HER2 were co-expressed at high levels in vitro in SKBR3, UACC-812, UACC-893 and MCF7-HER2 cells. Knockdown or functional antagonism of HER2 did not alter JAM-A expression in any cell line tested. Interestingly, however, JAM-A knockdown decreased HER2 and ER-α expression, resulting in reduced levels of phospho-(active) AKT without an effect on the extracellular signal-related kinase phosphorylation. The downstream effects of JAM-A knockdown on HER2 and phospho-AKT were partially reversed upon treatment with the proteasomal inhibitor MG132. We conclude that JAM-A is co-expressed with HER2 and associates with aggressive breast cancer phenotypes. Furthermore, we speculate that JAM-A may regulate HER2 proteasomal degradation and activity, potentially offering a promise as a therapeutic target in HER2-positive breast cancers.

Evidence for reduced neuronal somal size within the insular cortex in schizophrenia, but not in affective disorders

The insular cortex is a paralimbic area of the brain thought to have important roles in sensory integration, auditory hallucinations and language. Both structural and functional MRI studies have revealed that this brain area is abnormal in both size and activity in schizophrenia. Further investigation of this region at the cellular level in schizophrenia has not been carried out. In the current study, we conducted a stereological examination of neuronal and glial size and density in layers 2 and 3 of the dorso-caudal region of the insular cortex in 15 schizophrenic, 15 bipolar, 15 unipolar and 15 control patients. These cortical layers are candidate layers based on previous cytoarchitectual investigations. Statistical analysis (ANCOVA, correcting for pH, post-mortem interval and age) showed decreased neuronal volume in layer 2 in schizophrenia (p=0.0008, 16.2% mean reduction). No other significant changes were observed. This study thus provides the first evidence of cytoarchitectural abnormality of the insular cortex in the pathophysiology of schizophrenia but not mood disorders. Further work is needed to investigate the molecular basis for this neuronal abnormality in schizophrenia in order to elucidate its role in the pathophysiology of schizophrenia.

Immunopathogenesis of experimental Chagas' disease in mice: damage to the autonomic nervous system

Infection of mice with Trypanosoma cruzi produces pathological change which in many ways parallels the evolution of Chagas' disease in human patients. An essential element in this experimental pathology is the intense denervation observed during the resolution of acute-stage parasitaemia. Host cells, from a variety of tissues, have been shown to absorb parasite antigens and thus to become targets for the hosts' own anti-parasite immune response. The definition of common antigenic determinants, shared by T. cruzi and human neuronal cells, might explain why the electrical conduction systems and the autonomic nervous system are especially vulnerable to the postulated autoimmune process. We have the models, the tools and the hypotheses, and now we await the proof.

Regulation and function of spinal and peripheral neuronal B1 bradykinin receptors in inflammatory mechanical hyperalgesia

Activation of either B1 or B2 bradykinin receptors by kinins released from damaged tissues contributes to the development and maintenance of inflammatory hyperalgesia. Whereas B2 agonists activate sensory neurones directly, B1 agonists were thought only to have indirect actions on sensory neurones. The recent discovery of constitutive B1 receptor expression in the rat nervous system lead us to re-investigate the role of neuronal B1 receptors in inflammatory hyperalgesia. Therefore we have examined B1 bradykinin receptor regulation in rat dorsal root ganglia in a model of inflammatory hyperalgesia, and correlated it with hyperalgesic behaviour. Twenty-four hours after injection of Freund's complete adjuvant into one hindpaw, there was a significant increase in B1 protein expression (measured by immunohistochemistry) in both ipsilateral and contralateral dorsal root ganglion neurones, whereas axotomy resulted in reduction of B1 protein in ipsilateral dorsal root ganglia. In behavioural experiments, the B1 antagonist desArg10HOE140, administered by either intrathecal or systemic routes, attenuated Freund's complete adjuvant-induced mechanical hyperalgesia in the inflamed paw, but did not affect mechanical allodynia. The B1 agonist, desArg9BK, did not affect paw withdrawal thresholds in nai;ve rats following intraplantar administration into the paw, whilst intrathecal administration elicited mechanical hyperalgesia. However, after Freund's complete adjuvant-induced inflammation, desArg9BK caused a marked mechanical hyperalgesia, by either route, of the contralateral, uninflamed hindpaw, correlating with the observed contralateral and ipsilateral increases in receptor levels. Our results suggest a functional role for B1 receptors expressed both in the periphery and in the spinal cord, in mechanical hyperalgesia during inflammation.

Proteomic analysis of the cell-surface membrane in chronic lymphocytic leukemia: identification of two novel proteins, BCNP1 and MIG2B

B-cell-specific plasma-membrane proteins are potential targets for either small molecule or antibody-based therapies. We have sought to annotate proteins expressed at the cell surface membrane in patients with chronic lymphocytic leukemia (CLL) using plasma-membrane-based proteomic analysis to identify previously uncharacterized and potentially B-cell-specific proteins. Proteins from plasma-membrane fractions were separated on one-dimensional gels and trypsinized fractions subjected to high-throughput MALDI-TOF mass spectrometry. Using this method, many known B-cell surface antigens were detected, but also known proteins not previously described in this disease or in this cellular compartment, including cell surface receptors, membrane-associated enzymes and secreted proteins, and completely unknown proteins. To validate the method, we show that BLK, a B-cell-specific kinase, is located in the CLL-plasma-membrane fraction. We also describe two novel proteins (MIG2B and B-cell novel protein #1, BCNP1), which are expressed preferentially in B cells. MIG2B is in a highly conserved and defined gene family containing two plasma-membrane-binding ezrin/radixin/moesin domains and a pleckstrin homology domain; the Caenorhabditis elegans homolog (UNC-112) is a membrane-associated protein that colocalizes with integrin at cell-matrix adhesion complexes. BCNP1 is a completely unknown protein with three predicted transmembrane domains, with three alternatively spliced final exons. Proteomic analysis may thus define new potential therapeutic targets.

Modelling muscle motor conformations using low-angle X-ray diffraction

New results on myosin head organization using analysis of low-angle X-ray diffraction patterns from relaxed insect flight muscle (IFM) from a giant waterbug, building on previous studies of myosin filaments in bony fish skeletal muscle (BFM), show that the information content of such low-angle diffraction patterns is very high despite the 'crystallographically low' resolution limit (65 A) of the spacings of the Bragg diffraction peaks being used. This high information content and high structural sensitivity arises because: (i) the atomic structures of the domains of the myosin head are known from protein crystallography; and (ii) myosin head action appears to consist mainly of pivoting between domains which themselves stay rather constant in structure, thus (iii) the intensity distribution among diffraction peaks in even the low resolution diffraction pattern is highly determined by the high-resolution distribution of atomically modelled domain mass. A single model was selected among 5000+ computer-generated variations as giving the best fit for the 65 reflections recorded within the selected resolution limit of 65 A. Clear evidence for a change in shape of the insect flight muscle myosin motor between the resting (probably like the pre-powerstroke) state and the rigor state (considered to mimic the end-of-powerstroke conformation) has been obtained. This illustrates the power of the low-angle X-ray diffraction method. The implications of these new results about myosin motor action during muscle contraction are discussed.

Treatment of pulmonary artery compression due to fibrous mediastinitis with endovascular stent placement

We present the case of a 32-year-old woman with high-grade right pulmonary artery stenosis secondary to fibrous mediastinitis. The patient was managed with balloon angioplasty and stent placement. Only 15 cases of this nature have been reported in the literature, and this is one of the first to be managed with endovascular stent placement.

Maximizing the use of a Web-based teaching skills curriculum for community-based volunteer faculty

BACKGROUND

The University of Kansas School of Medicine in Wichita created an Internet-based faculty development curriculum for community-based faculty. Because relatively few physicians use Internet-based continuing medical education (CME), the most cost-effective methods of encouraging use need to be identified.

METHOD

Five interventions intended to increase use of the curriculum were assessed. The number of times the CME curriculum Webpages were accessed was correlated with the interventions.

RESULTS

Demonstrating the Website to faculty at a semiannual meeting elicited the most Website "hits." Electronic mail and flyers also appeared to be effective in stimulating interest in the Website. Only four community-based faculty applied for CME credit for completing the curricular modules.

FINDINGS

Multiple modalities should be used in advertising and stimulating interest in an Internet-based faculty development curriculum. Demonstrating the Website to faculty at a meeting appeared to achieve the greatest return. Offering CME credit was not helpful in stimulating interest.

The computed tomographic enhancement pattern of the normal canine pituitary gland

Dynamic computed tomography (CT) of the pituitary gland was performed on four healthy male dogs of similar size, weight and age. The pituitary gland region was first identified on lateral scout and transverse non-contrast images. After localization, water soluble iodinated contrast medium was administered intravenously as a bolus at a dose of 1 ml/lb using a pressure injector at an injection rate of 10 ml/sec and a total of 40 post contrast images of the pitutary gland were acquired. No images were made after 400 seconds. The same pituitary region was imaged in each slice. The slice thickness was 1.5 mm, with a two second scan time and an eight second delay between images (resulting in images every ten seconds). The contrast medium injection and initial image were acquired simultaneously, resulting in a non-contrast enhanced initial image. At the completion of the CT scan, a region of interest (ROI) was drawn around the pituitary gland and time density data were obtained. The mean pituitary Hounsfield number was plotted as a function of time. A bi-exponential least squares model was used to derive the best fitting line through the data. The mean relative peak increase in pituitary Hounsfield Units (HU) was 65.9% +/- 2.1%. After the initial increase there was a decrease in pituitary Hounsfield number with a half-time of 16.1 seconds, followed by a slower phase with a half-time of 16.5 minutes. The mean pituitary gland HU value during the period of gradual opacity decline was 35.0% +/- 4.4% above that of the pre-contrast image. Establishing the enhancement pattern in the canine pituitary gland is the precursor to the clinical application of dynamic CT of the pituitary gland to diagnose pituitary microadenomas and/or small macroadenomas before they become exceptionally large.

Changing pattern of organ dysfunction in early human sepsis is related to mortality

OBJECTIVE

We examined the pattern of organ system dysfunction, the evolution of this pattern over time, and the relationship of these features to mortality in patients who had sepsis syndrome.

DESIGN

Prospective, multicenter, observational study.

SETTING

Intensive care units in tertiary referral teaching hospitals.

PATIENTS

A total of 287 patients who had sepsis syndrome were prospectively identified in intensive care units. MATERIALS AND MEASUREMENTS: Cardiovascular, pulmonary, neurologic, coagulation, renal, and hepatic dysfunction were assessed at onset and on day 3 of sepsis syndrome. Organ dysfunction was classified as normal, mild, moderate, severe, and extreme dysfunction. We calculated the occurrence rate and associated 30-day mortality rate of organ dysfunction at the onset of sepsis syndrome. We then measured the change in organ dysfunction from onset to day 3 of sepsis syndrome and determined, for individual organ systems, the associated 30-day mortality rate.

RESULTS

At the onset of sepsis syndrome, clinically significant pulmonary dysfunction was the most common organ failure, but was not related to 30-day mortality. Clinically significant cardiovascular, neurologic, coagulation, renal, and hepatic dysfunction were less common at the onset of sepsis syndrome but were significantly associated with the 30-day mortality rate. Worsening neurologic, coagulation, and renal dysfunction from onset to day 3 of sepsis syndrome were associated with significantly higher 30-day mortality than with improvement or no change in organ dysfunction.

CONCLUSIONS

Increased mortality rate in sepsis syndrome is associated with a pattern characterized by failure of nonpulmonary organ systems and, in particular, worsening neurologic, coagulation, and renal dysfunction over the first 3 days. Although initial pulmonary dysfunction is common in patients with sepsis syndrome, it is not associated with an increased mortality rate.

Detection of the human immunodeficiency virus regulatory protein tat in CNS tissues

Neuropathologically, human immunodeficiency virus (HIV) is associated with a range of inflammatory disorders, extensive cortical neuronal loss, and dendritic and synaptic damage. Although the mechanisms resulting in these abnormalities are still unclear, the neurotoxic effects are thought to be due in part to viral products including the tat gene product. We have previously shown that Tat when presented to neurons extracellularly interacts with neuronal cell membranes to cause neuronal excitation and toxicity in fmole amounts. To determine the role of Tat in mediating HIV encephalitis (HIVE), we detected tat mRNA and protein in tissue extracts of nine patients with HIVE and seven patients without HIVE. Despite long autopsy times and significant degradation, tat mRNA was detected in 4/9 patients with HIVE but not in any of the seven patients without dementia. Similarly, the env mRNA was also detected in 5/9 patients with HIVE but not in the patients without HIVE. However, vif mRNA was detected in both groups of patients with (5/9) or without (2/7) HIVE. Using protein extracts from the brains of the same groups of patients we were unable to detect Tat by enzyme linked immunosorbant assay (ELISA) (sensitivity of 2 ng Tat/ml of brain tissue). However, Tat could be detected immunohistochemically and in protein extracts from the brains of rhesus macaques with encephalitis due to a chimeric strain of HIV and simian immunodeficiency virus (SHIV). Our observations support the role of Tat in the neuropathogenesis of HIV and SHIV encephalitis.

Myosin crossbridge configurations in equilibrium states of vertebrate skeletal muscle. Heads swing axially or turn upside-down between resting and rigor

The positions and orientations of the myosin heads in relaxed, active, rigor and S1-labelled fish muscle are being determined by analysis both of electron micrographs and of low-angle X-ray diffraction patterns. The X-ray analysis of resting muscle makes use of the head shape defined from the study of S1 crystals, with variable head configurational parameters being used on each of the three different 3-fold symmetric 14.3 nm-spaced 'crowns' of myosin heads within the 42.9 nm axial repeat of the myosin filaments. Diffraction patterns were stripped using CCP13 fibre diffraction software. Searches and optimisation were carried out using simulated annealing and local refinement procedures to give a 'best fit' relaxed structure with a crystallographic R-factor of about 4%. It had heads oriented all the same way up (i.e. with similar rotations around their own long axes) on the myosin filament, but with a small range of axial tilts. Head configuration in rigor fish muscle is being determined by X-ray diffraction and electron microscopy of normal rigor muscle and of skinned muscle soaked with extrinsic myosin S1. Computed 3-D reconstructions of acto-S1 using X-ray amplitudes and phases from electron microscopy are informative and help to analyse the X-ray diffraction data that extend axially to about 1 nm resolution. An ambiguity is the axial direction of the observed resting myosin head array relative to the known polarity of the actin filaments. One polarity would give little axial displacement (2-3 nm) between opposite ends of the resting and rigor heads, and in this case the heads would need to rotate around their own long axes by about 115 degrees to make a rigor attachment. The other (preferred) filament polarity would provide considerable axial swinging (14-15 nm) between the two states. We are attempting to define the absolute polarity of the resting muscle myosin head array using electron microscopy and image processing either of cryo-sections or of replicas from shadowed, freeze-fractured, rapidly frozen fish muscle fibres.

Comparative analysis of matrix metalloproteinases by immunocytochemistry, immunohistochemistry and zymography in human primary brain tumours

Matrix metalloproteinases (MMPs) are a growing family of zinc-dependent endopeptidases which are characterised by their ability to degrade various extracellular matrix (ECM) components. The family includes collagenases, gelatinases, stromelysins, metalloelastase and membrane type metalloproteinases. Consistent with their proteolytic activities, MMPs have been implicated in a variety of physiological and pathological conditions, such as normal embryogenesis, tissue morphogenesis and are thought to play a role in facilitating tumour cell invasion of the normal brain. In this comparative study, we have used zymography, immunohistochemical and immunocytochemical techniques to demonstrate the expression of gelatinase-A and B (MMP-2 and 9, respectively) and membrane type metalloproteinase (MMP-14) in 8 intrinsic human primary brain tumours of various histological type and grade. Zymography results showed that MMP-2 was the most prominent proteolytic enzyme in all the cell lines studied (with one exception), while MMP-9 was only faintly expressed. However, the corresponding paraffin sections showed no expression of either MMP-2, 9 or 14 within the tumour cells, positivity being confined to haematogenous cells and the vascular endothelium. Fluorescence immunocytochemical studies, using monoclonal antibodies to MMP-2, 9 and 14, showed granular cytoplasmic reactivity in vitro. In addition, there was strong focal positivity at the cell membrane with MMP-14 in some high grade tumours suggesting that MMPs are produced at the leading edge of the cell by individual subpopulations of invading glia, in small quantities and on demand in vivo. It can be concluded that local microenvironmental conditions in vitro appear to stimulate such MMP activity.

Myosin rod-packing schemes in vertebrate muscle thick filaments

Muscle myosin filament backbones are known to be aggregates of long coiled-coil alpha-helical myosin rods, but the packing arrangement is not understood in detail. Here we present new data on fish muscle myosin filaments from low-angle X-ray diffraction and from freeze-fracture, deep-etch electron microscopy which put constraints on the kind of models that might explain all of the observations. In particular, it is known in the case of vertebrate striated muscle thick filaments that the myosin head array in resting muscle is not perfectly helical but contains periodic perturbations. We show by analysis of low-angle X-ray diffraction patterns from resting bony fish muscle that any radial, azimuthal, and axial perturbations of the myosin head origins on the filament surface (due to perturbed myosin rod packing) must all be rather small and that the main perturbations are in the myosin head configurations (i.e., tilts, slews, rotations) on those origins. We provide evidence that the likely arrangement of titin molecules on the myosin filament is with them aligned parallel to the filament long axis, rather than following helical tracks. We also show from freeze-fracture studies of fish muscle that the myosin filament backbone (including titin and other extra proteins) has a radius of about 65-75 A and appears to contain a small (approximately 15-20 A radius) hollow core. Together with previously published evidence showing that the myosin rods are nearly parallel to the thick filament long axis, these results are consistent with the curved crystalline layer model of Squire (J. M. Squire, 1973, J. Mol. Biol. 77, 291-323), and they suggest a general structure for the C-zone part of the thick filament

The American-European Consensus Conference on ARDS, part 2: Ventilatory, pharmacologic, supportive therapy, study design strategies, and issues related to recovery and remodeling. Acute respiratory distress syndrome

The acute respiratory distress syndrome (ARDS) continues as a contributor to the morbidity and mortality of patients in intensive care units throughout the world, imparting tremendous human and financial costs. During the last 10 years there has been a decline in ARDS mortality without a clear explanation. The American-European Consensus Committee on ARDS was formed to re-evaluate the standards for the ICU care of patients with acute lung injury (ALI), with regard to ventilatory strategies, the more promising pharmacologic agents, and the definition and quantification of pathologic features of ALI that require resolution. It was felt that the definition of strategies for the clinical design and coordination of studies between centers and continents was becoming increasingly important to facilitate the study of various new therapies for ARDS.

The American-European Consensus Conference on ARDS, part 2. Ventilatory, pharmacologic, supportive therapy, study design strategies and issues related to recovery and remodeling

The acute respiratory distress syndrome (ARDS) continues as a contributor to the morbidity and mortality of patients in intensive care units throughout the world, imparting tremendous human and financial costs. During the last ten years there has been a decline in ARDS mortality without a clear explanation. The American-European Consensus Committee on ARDS was formed to re-evaluate the standards for the ICU care of patients with acute lung injury (ALI), with regard to ventilatory strategies, the more promising pharmacologic agents, and the definition and quantification of pathological features of ALI that require resolution. It was felt that the definition of strategies for the clinical design and coordination of studies between centers and continents was becoming increasingly important to facilitate the study of various new therapies for ARDS.

Myosin head configuration in relaxed fish muscle: resting state myosin heads must swing axially by up to 150 A or turn upside down to reach rigor

The arrangement and shape of myosin heads in relaxed muscle have been determined by analysis of low-angle X-ray diffraction data from a very highly ordered vertebrate muscle in bony fish. This reveals the arrangement and interactions between the two heads of the same myosin molecule, the shape of the resting myosin head (M.ADP.Pi) assuming a putative hinge between the myosin catalytic domain and the light chain binding-domain, and the way that the actin-binding sites on myosin are arrayed around the actin filaments in the bony fish muscle A-band cell unit. The results are discussed in terms of possible force-generating mechanisms. Changes in myosin head shape or tilt have been implicated in the mechanism of force generation. The myosin head arrangement, including perturbations from perfect helical symmetry, has all heads oriented roughly the same way up (there is only a small range of rotations around the head long axis). X-ray data do not define the absolute polarity of the myosin head array. The resting head rotation is either similar to (65 degrees difference) or opposite to (115 degrees difference) the rotation in the rigor state. If the rotations are similar, probably the more likely possibility, then the average relative axial displacement of the inner and outer ends of the heads from the resting state to rigor is about 140 to 150 A. If (less likely) the resting head rotation is opposite to rigor, then the heads would need to turn over (i.e. rotate about 115 degrees around their own long axes) and the mean relative axial displacement from relaxed to rigor would only be 20 to 30 A.

Decreased absolute levels of ascorbic acid and unaltered vasoactive intestinal polypeptide receptor binding in the frontal cortex in acquired immunodeficiency syndrome

VIP receptor binding in the frontal cortex, a region with substantial neuronal loss, was unaltered in individuals who had died of acquired immunodeficiency syndrome (AIDS) neurotoxicity. In contrast, ascorbic acid, which suppresses human immunodeficiency virus (HIV) replication and modulates glutamatergic neuronal activity, was reduced by nearly 60% in the same brain region. These findings indicate that while neurons containing ascorbic acid may be lost, vasoactive intestinal polypeptide (VIP) receptor bearing cells remain viable. This finding supports previous observations that VIP prevents HIV induced neuronal death. The reduced ascorbic acid levels may contribute to particular neurons being vulnerable to damage from oxidative stress and possibly clinically to the development of dementia.

Aberrant crypt foci in the colonic mucosa of rats treated with a genotoxic and nongenotoxic colon carcinogen

Aberrant crypt foci (ACFs) are putative preneoplastic lesions in the colonic mucosa identified by examining methylene blue-stained whole mounts of colon. ACFs have been previously described in rats treated with genotoxic colon carcinogens. This study determined whether or not a nongenotoxic colon carcinogen could induce ACFs and compared the morphology of these ACFs with those induced by a genotoxic colon carcinogen. Six-wk-old Fischer-344 rats were administered dextran sulfate (DSS, nongenotoxin) in the drinking water or azoxymethane (AOM, genotoxin) by single subcutaneous injection. Rats were sacrificed at 9 and 14 wk after study initiation. Colons were fixed and stained with methylene blue, and the mucosal surface of transilluminated whole mounts was examined with a microscope. The number of ACFs and number of crypts per focus (multiplicity) were recorded. Representative ACFs were processed into glycol methacrylate for hexosaminidase enzyme histochemistry and sections of the remaining colon containing ACFs were embedded in paraffin for morphologic evaluation. In whole mounts, ACFs from AOM- and DSS-treated rats had elongated slit-to-oval-shaped lumens surrounded by a thickened and intensely stained epithelium. DSS-induced aberrant crypts differed from those induced by AOM in that they were frequently larger, tended not to form discrete foci circumscribed by normal crypts, and were located adjacent to ulcers. Total ACFs and large foci (4 or more crypts/focus) were significantly more numerous in AOM-treated rats at both time points. Histologically, DSS-induced ACFs had segmental to diffuse loss of hexosaminidase activity, mucin depletion to increased prominence of goblet cells, and marked distortion of crypt architecture. AOM-induced ACFs had diffuse loss of hexosaminidase activity, variable depletion of mucin, and less distortion of crypt architecture. Variable degrees of epithelial dysplasia were seen in ACFs with both carcinogens, but dysplasia was more severe in DSS-induced ACFs. Colonic mucosal neoplasms were induced by both carcinogens. In subchronic studies, the ACF assay may be a useful method to improve the identification and characterization of xenobiotic-induced changes in colonic mucosal crypts.

Decreased expression of AMPA receptor messenger RNA and protein in AIDS: a model for HIV-associated neurotoxicity

HIV infection can cause extensive neuronal loss and clinically a severe dementia. The cause of the neurotoxicity remains unclear as neurons are not infected, but disturbance of glutamate-linked calcium entry has been implicated. In this study, we have shown a decrease in HIV-infected brain of the expression of mRNA and protein of the GluR-A flop subtype of alpha-amino-3-hydroxy-5-methyl-4-isoxazole propionic acid (AMPA) glutamate receptor in cerebellar Purkinje cells. Although Purkinje cells are relatively resistant to loss, the observed disturbance of AMPA receptors may contribute to the neurotoxic process in other vulnerable brain regions and clinically to the development of dementia.

The pathology and nosology of primary progressive aphasia

We present three cases of primary progressive aphasia (PPA) with Pick-variant pathology to support a hypothesis of an underlying nosologic relatedness. Neuropathologic examination demonstrated focal brain atrophy with corresponding neuronal loss and gliosis, accompanied by superficial spongiosis. Specific histologic findings were ballooned neurons (Pick cells) in the atrophic areas, and in two of the cases, Pick bodies. They were immunoreactive for tau. In contrast to classic Pick's disease, there were no Pick bodies in the hippocampus. The intense neurofilament immunoreactivity of the perikarya of the ballooned neurons greatly facilitated their recognition. Based on our cases and a critical review of the literature, we hypothesize that the common underlying pathology of PPA is a variant of Pick's disease. Furthermore, we propose the concept of "Pick complex" to include other neurodegenerative diseases characterized by focal cortical degeneration, such as PPA, frontal lobe dementia, ALS with PPA, and corticonigral and corticobasal ganglionic degenerations.

Plasticity in the adult human oligodendrocyte lineage

Preoligodendrocytes have been described in cultures and tissue prints of adult human white matter (Armstrong et al., 1992). To characterize further these precursors of human oligodendrocytes, we have investigated whether they express genes playing a critical role in oligodendrocyte development. In the intact human brain, platelet-derived growth factor receptor alpha (PDGF alpha R) and myelin transcription factor 1 (MyTI) transcripts are expressed in 1-2% of cells of the oligodendrocyte lineage (OL), and clusters of such cells can be found in the periventricular region. Myelin basic protein transcripts containing exon 2 information (exon 2+ MBP), which are characteristic of the premyelinating stage, are detected in 15-20% of OL cells in vivo. When OL cells are separated from human white matter and allowed to regenerate in vitro, a much larger proportion of these cells express developmentally regulated genes, while exon 2- MBP and proteolipid protein (PLP) transcripts characteristic of mature OL cells appear transiently downregulated. Basic fibroblast growth factor (bFGF), even in the presence of PDGF, does not promote DNA synthesis in these cultured OL cells. Yet bFGF induces human oligodendrocytes to regenerate their processes rapidly in vitro and to express O4 antigens as well as exon 2+ MBP, MyTI, and PLP transcripts. While bFGF accelerates early regenerative processes, it also maintains high expression of exon 2+ MBP transcripts in OL cells for up to 2 weeks in vitro. In contrast, high levels of insulin in the absence of bFGF allow accumulation of exon 2- MBP and PLP transcripts in most OL cells at 2-3 weeks in vitro. We propose that the myelinated human brain harbors a small pool of precursors of oligodendrocytes and that growth factor-regulated phenotypic plasticity rather than mitogenic potential accounts for the regeneration of oligodendrocytes in the initial stages of demyelinating diseases such as multiple sclerosis.

Maternal-fetal HLA sharing and risk of newborn encephalopathy and seizures: a pilot study

A pilot case-control study was done to collect data on whether susceptibility to newborn encephalopathy and neonatal seizures is influenced by the degree of maternal-fetal sharing of HLA antigens. Cases included 13 infants with moderate or severe newborn encephalopathy and seven infants with neonatal seizures but no other signs of encephalopathy. Controls were neurologically normal infants matched to cases by date of birth, sex, race, and payment status. Infants and their mothers were typed for HLA-A, -B, -DR, and -DQ antigens. The observed frequency of sharing of maternal antigens was greater than expected (ie, 0.5) for cases compared to controls at the HLA-B, -DR, and -DQ loci but not for HLA-A. The risk of neurologic problems in the neonatal period was increased 6.3 times when there was more than one match at the HLA-DR or -DQ locus. Placental abnormalities were noted at delivery only among cases, and the mean placental weight in cases was 598 g versus 695 g in controls. Further studies with sample sizes sufficiently large to statistically test this hypothesis are needed.

Report of the American-European Consensus conference on acute respiratory distress syndrome: definitions, mechanisms, relevant outcomes, and clinical trial coordination. Consensus Committee

The acute respiratory distress syndrome (ARDS), a process of nonhydrostatic pulmonary edema and hypoxemia associated with a variety of etiologies, carries a high morbidity rate, mortality rate (10% to 90%), and financial cost. The reported annual incidence in the United States is 150,000 cases, but this figure has been challenged and may be different in Europe. Part of the reason for these uncertainties is the heterogeneity of diseases underlying ARDS and the lack of uniform definitions for ARDS. Thus, those who wish to know the true incidence and outcome of this clinical syndrome are stymied. The European American Consensus Committee on ARDS was formed to focus on these issues and on the pathophysiologic mechanisms of the process. It was felt that international coordination between North America and Europe in clinical studies of ARDS was becoming increasingly important to address the recent plethora of potential therapeutic agents for the prevention and treatment of ARDS.

The American-European Consensus Conference on ARDS. Definitions, mechanisms, relevant outcomes, and clinical trial coordination

The acute respiratory distress syndrome (ARDS), a process of nonhydrostatic pulmonary edema and hypoxemia associated with a variety of etiologies, carries a high morbidity, mortality (10 to 90%), and financial cost. The reported annual incidence in the United States is 150,000 cases, but this figure has been challenged, and it may be different in Europe. Part of the reason for these uncertainties are the heterogeneity of diseases underlying ARDS and the lack of uniform definitions for ARDS. Thus, those who wish to know the true incidence and outcome of this clinical syndrome are stymied. The American-European Consensus Committee on ARDS was formed to focus on these issues and on the pathophysiologic mechanisms of the process. It was felt that international coordination between North America and Europe in clinical studies of ARDS was becoming increasingly important in order to address the recent plethora of potential therapeutic agents for the prevention and treatment of ARDS.

Report of the American-European consensus conference on ARDS: definitions, mechanisms, relevant outcomes and clinical trial coordination. The Consensus Committee

The acute respiratory distress syndrome (ARDS), a process of non-hydrostatic pulmonary edema and hypoxemia associated with a variety of etiologies carries a high morbidity, mortality (10-90%) and financial cost. The reported annual incidence in the United States is 150,000 cases, but this figure has been challenged and may be different in Europe. Part of the reason for these uncertainties is the heterogeneity of diseases underlying ARDS and the lack of uniform definitions for ARDS. Thus, those whose wish to know the true incidence and outcome on this clinical syndrome are stymied. The European American Consensus Committee on ARDS was formed to focus on these issues and on the pathophysiologic mechanisms of the process. It was felt that international coordination between North America and Europe in clinical studies of ARDS was becoming increasingly important in order to address the recent plethora of potential therapeutic agents for the prevention and treatment of ARDS.

Analysis of the anatomical distribution of GAD67 mRNA encoding truncated glutamic acid decarboxylase proteins in the embryonic rat brain

During development of the central nervous system (CNS) the gene that encodes the 67 kDa form of glutamic acid decarboxylase (GAD) undergoes alternative splicing. The alternatively spliced variants include an exon (referred to as ES, for embryonic stop) that contains a premature stop codon. The detection of mRNA containing the ES exon in embryonic rat brain has been previously reported (Proc. Natl. Acad. Sci., 87 (1990) 8771-8775). We have used in situ hybridization to identify the anatomical distribution of ES mRNA in the embryonic rat brain during two stages of development, embryonic day 17 (E17) and E20. At E17, GAD67 mRNA was expressed in several CNS regions that were destined to contain GABAergic neurons when mature. ES transcripts were predominantly localized to ventricular zones and other regions associated with populations of proliferative cells at E17 and E20. At both ages, however, the alternatively spliced variants were also detected in regions of brain associated with migratory or post-mitotic neurons. GAD67 transcripts that did not include the ES exon were localized to anatomical areas that contained post-mitotic, and often post-migratory neurons. The temporal and spatial disappearance of mRNA containing the ES exon generally followed a caudal-to-rostral gradient which paralleled neuronal terminal mitosis and differentiation.