Distinct genomic and immunologic tumor evolution in germline TP53-driven breast cancers

Pathogenic germline TP53 alterations cause Li-Fraumeni Syndrome (LFS), and breast cancer is the most common cancer in LFS females. We performed first of its kind multimodal analysis of LFS breast cancer (LFS-BC) compared to sporadic premenopausal BC. Nearly all LFS-BC underwent biallelic loss of TP53 with no recurrent oncogenic variants except ERBB2 (HER2) amplification. Compared to sporadic BC, in situ and invasive LFS-BC exhibited a high burden of short amplified aneuploid segments (SAAS). Pro-apoptotic p53 target genes BAX and TP53I3 failed to be up-regulated in LFS-BC as was seen in sporadic BC compared to normal breast tissue. LFS-BC had lower CD8+ T-cell infiltration compared to sporadic BC yet higher levels of proliferating cytotoxic T-cells. Within LFS-BC, progression from in situ to invasive BC was marked by an increase in chromosomal instability with a decrease in proliferating cytotoxic T-cells. Our study uncovers critical events in mutant p53-driven tumorigenesis in breast tissue.

Abstract 2608: Defining the function of tumor suppressor p53 arginine 181 residue in tumorigenesis

The gene Tp53 encodes for the protein p53 which has many tumor suppressive functions. Li-Fraumeni syndrome is characterized by germline Tp53 mutations that significantly increase the risk of cancer. The p53 amino acid residue arginine 181 is one such mutation site that promotes tumorigenesis by impacting a phenomenon known as p53 cooperativity. This is the ability of one p53 molecule to interact with another in order to efficiently bind specific sites on DNA to enact specific p53 functional pathways. Two p53 molecules interact with each other through the formation of a salt bridge between H1 helices found in respective DNA binding domains. The two key amino acid residues in this salt bridge are positively charged arginine (R) 181 and negatively charged glutamic acid (E) 180 which form electrostatic interactions with the residues on the opposite p53 H1 helix. Cooperativity mutants such as R181H and R181C show a hypomorphic behavior wherein much of p53’s canonical functions remain intact. Colony suppression data show that H1299 cells with p53 R181H and R181C yield a similar number of colonies as p53 wild type, which is significantly fewer than the yield of p53 hotspot mutation R175H and the absence of p53. Despite retaining some wild-type behavior, R181 mutants are found in LFS patients with cancer. Discovering the importance of the R181 residue for p53’s role in defending against tumorigenesis can lead to unique treatment opportunities for LFS patients with cooperativity mutants.

Citation Format: Renyta Moses, Gregory Kelly, Alexandra Indeglia, Sven Miller, John Karanicolas, Maureen Murphy, Kara Maxwell. Defining the function of tumor suppressor p53 arginine 181 residue in tumorigenesis [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 2608.

A185 SUSTAINED SYMPTOM CONTROL WITH MIRIKIZUMAB IN PATIENTS WITH MODERATELY TO SEVERELY ACTIVE ULCERATIVE COLITIS IN THE LUCENT-2 MAINTENANCE TRIAL

Background

Mirikizumab (miri) improved symptom control in a Phase 3, multicenter, randomized, double-blind, parallel, placebo-controlled induction study at Week (W)12, in patients (pts) with moderately-to-severely active ulcerative colitis (UC; LUCENT-1).

Purpose

This analysis assessed sustained symptom control during the maintenance phase through W40 (W52 of continuous therapy), among pts who were induced into clinical response with miri.

Method

During the 40W maintenance study (LUCENT-2), pts (N=544) who achieved clinical response to miri 300mg Q4W by W12 of induction, were re-randomized 2:1 to subcutaneous (SC) miri 200mg (n=365) or PBO Q4W (n=179). We evaluated sustained control of stool frequency (SF), rectal bleeding (RB), bowel movement urgency (BU) and abdominal pain (AP). The proportion of pts achieving SF Remission (defined as SF=0, or SF=1 with a ≥1-point decrease from induction baseline [BL]), RB Remission (RB=0), Symptomatic Remission (both SF and RB Remission), Stable Maintenance of Symptomatic Remission (defined as pts in Symptomatic Remission for at least 7 out of 9 visits from W4 to W36 and also at Week 40 among pts in Symptomatic Remission and Clinical Response at the end of LUCENT-1), and AP Improvement (Numeric Rating Scale [NRS] pain score ≥30% improvement from BL in pts with baseline AP NRS ≥3) were assessed. BU NRS change from baseline, and the proportion of pts achieving BU Remission (NRS 0 or 1 in pts with BU NRS ≥3 at baseline) were evaluated.

Result(s)

A greater proportion of miri-treated pts achieved SF Remission, RB Remission and Symptomatic Remission compared to PBO at W40 (Table), with significant differences observed from W8 of LUCENT-2 (p=0.042; p=0.004; p=0.036, respectively) and maintained through W40. Miri-treated pts had a significantly higher percentage of Stable Maintenance of Symptomatic Remission (p<0.001). Pts in the miri-treatment group had a significantly greater mean reduction in BU NRS change from induction BL starting at W12 (p=0.034) onwards compared to PBO (Table). Pts assigned to miri accrued an additional 13.6 percentage-point benefit in BU Remission during the first 8W of maintenance therapy and achieved a significant greater improvement at W40 compared to PBO (p<0.001, Table). Similarly, AP was significantly improved for the miri-treated group starting at W16 (p=0.034) onwards compared to PBO.

Image

Conclusion(s)

Miri provides sustained control of UC symptoms including BU, RB, and SF compared to PBO in pts with moderately to severely active UC.

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Other

Please indicate your source of funding;

Eli Lilly and Company

Disclosure of Interest

A. Dignass Consultant of: AbbVie, Abivax, Amgen, Arena Pharmaceuticals, Bristol Myers Squibb (Celgene), Celltrion, Dr. Falk Pharma, Eli Lilly and Company, Ferring Pharmaceuticals, Fresenius Kabi, Galapagos, Gilead Sciences, Janssen, Merck Sharp & Dohme, Novartis, Pfizer, Pharmacosmos, Roche, Sandoz/Hexal, Takeda, Tillotts Pharma AG, and Vifor Pharma; has received lecture fees or honoraria from: AbbVie, Amgen, Bristol Myers Squibb, Dr. Falk Pharma, Ferring Pharmaceuticals, Galapagos, High5Md, Janssen, Materia, Merck Sharp & Dohme, Pfizer, Sandoz, Takeda, Tillotts Pharma AG, and Vifor Pharma, S. Danese Consultant of: AbbVie, Alimentiv, Allergan, Amgen, AstraZeneca, Athos Therapeutics, Biogen, Boehringer Ingelheim, Bristol Myers Squibb, Celgene, Celltrion, Dr. Falk Pharma, Eli Lilly and Company, Enthera, Ferring Pharmaceuticals, Gilead Sciences, Hospira, Inotrem, Janssen, Johnson & Johnson, Merck Sharp & Dohme, Mundipharma, Mylan, Pfizer, Roche, Sandoz Sublimity, Takeda, TiGenix, UCB Pharma, and Vifor Pharma, Speakers bureau of: AbbVie, Amgen, Ferring Pharmaceuticals, Gilead Sciences, Janssen, Mylan, Pfizer, and Takeda, K. Matsuoka Grant / Research support from: AbbVie, EA Pharma, JIMRO, Kissei Pharmaceutical, Kyowa Kyorin, Mitsubishi Tanabe, Mochida Pharmaceutical, and Zeria Pharmaceutical Nippon; lecture fees from: AbbVie, EA Pharma, JIMRO, Kissei Pharmaceutical, Kyowa Kyorin, Mitsubishi Tanabe, Mochida Pharmaceutical, Takeda, and Zeria Pharmaceutical Nippon, M. Ferrante Grant / Research support from: AbbVie, Amgen, Biogen, Janssen Cilag, Pfizer, Takeda, and Viatris, Consultant of: AbbVie, Boehringer Ingelheim, Celltrion, Eli Lilly and Company, Janssen Cilag, Medtronic, Merck Sharp & Dohme, Pfizer, Regeneron, Sandoz, Takeda, and Thermo Fisher Scientific, Speakers bureau of: AbbVie, Amgen, Biogen, Boehringer Ingelheim, Celltrion, Dr. Falk Pharma, Eli Lilly and Company, Ferring Pharmaceuticals, Janssen, Lamepro, Medtronic, Merck Sharp & Dohme, Mylan, Pfizer, Samsung Bioepis, Sandoz, Takeda, and Thermo Fisher Scientific, M. Long Consultant of: AbbVie, Bristol Myers Squibb, Calibr, Eli Lilly and Company, Genentech, Janssen, Pfizer, Prometheus Biosciences, Roche, Takeda, TARGET PharmaSolutions, and Theravance Biopharma, I. Redondo Employee of: Eli Lilly and Company, T. Gibble Employee of: Eli Lilly and Company, R. Moses Employee of: Eli Lilly and Company, X. Li Employee of: Eli Lilly and Company, N. Morris Employee of: Eli Lilly and Company, C. Milch Employee of: Former employee, was employed at Eli Lilly and Company at the time of study, M. Abreu Grant / Research support from: Pfizer, Prometheus Biosciences, and Takeda, Consultant of: AbbVie, Arena Pharmaceuticals, Bristol Myers Squibb, Eli Lilly and Company, Gilead Sciences, Janssen, Microba Life Sciences, Prometheus Biosciences, UCB Pharma, and WebMD, Speakers bureau of: Alimentiv, Intellisphere LLC (HCP Live Institutional Perspectives in GI), Janssen, Prime CME, and Takeda, J. Jones: None Declared

A184 EARLY SYMPTOM CONTROL WITH MIRIKIZUMAB IN PATIENTS WITH MODERATELY TO SEVERELY ACTIVE ULCERATIVE COLITIS IN THE LUCENT-1 INDUCTION TRIAL

Background

Mirikizumab (miri), an anti-IL23/p19 monoclonal antibody, demonstrated efficacy compared with placebo (PBO) in the Phase 3, multicentre, randomized, double-blind LUCENT-1 induction study in patients with moderately to severely active ulcerative colitis (UC, NCT03518086).

Purpose

This analysis assessed early onset of symptomatic improvement and symptomatic control during induction.

Method

During the 12-week (W) induction study, 1162 adult patients (pts) with inadequate response, loss of response, or were intolerant to conventional therapy or biologic or tofacitinib therapy for UC, received miri IV Q4W (N=868) or PBO (N=294). We evaluated improvement for symptoms of stool frequency (SF), rectal bleeding (RB) and bowel movement urgency (BU), abdominal pain and fatigue. BU Numeric Rating Scale (NRS) change from baseline (BL), BU Clinical Meaningful Improvement (CMI), BU Remission, Fatigue NRS change from BL, Abdominal Pain Improvement, as well as SF Remission, RB Remission, Symptomatic Response and Symptomatic Remission were assessed.

Result(s)

As early as W2, miri-treated pts achieved a significantly greater reduction in RB subscores (p=0.001) and in SF subscores (p=0.035). From W2 and W4, a significantly greater percentage achieved SF Remission and RB Remission, respectively compared to PBO. A significantly greater percentage of miri-treated pts achieved Symptomatic Response compared to PBO from W2 (p=0.003) and of Symptomatic Remission compared with PBO from W4 (p<0.001). Miri-treated pts showed a significantly greater mean reduction in BU NRS scores as early as W2 compared to PBO (p=0.004). From W4, a significantly greater percentage of miri-treated pts achieved BU CMI versus PBO (p=0.044). From W7 onwards, a significantly greater percentage achieved BU Remission (p=0.002). The pts showed a significantly greater mean reduction in Fatigue NRS scores from W2 compared to PBO (p=0.014). As early as W4, a significant reduction of at least 30% in Abdominal Pain NRS score from BL was observed in the miri-treated pts compared with PBO (p=0.007). At W12, a significantly greater proportion of miri-treated pts achieved Symptomatic Response, Symptomatic Remission, RB Remission, SF Remission, BU change from BL, BU CMI and Remission, as well as Fatigue and Abdominal Pain Improvement, compared to PBO (Table).

Image

Conclusion(s)

Miri provides rapid control of UC symptoms, including BU and fatigue, as early as W2 compared with PBO in pts with moderately to severely active UC.

Please acknowledge all funding agencies by checking the applicable boxes below

Other

Please indicate your source of funding;

Eli Lilly and Company

Disclosure of Interest

S. Danese Consultant of: AbbVie, Alimentiv, Allergan, Amgen, AstraZeneca, Athos Therapeutics, Biogen, Boehringer Ingelheim, Bristol Myers Squibb, Celgene, Celltrion, Dr. Falk Pharma, Eli Lilly and Company, Enthera, Ferring Pharmaceuticals, Gilead Sciences, Hospira, Inotrem, Janssen, Johnson & Johnson, Merck Sharp & Dohme, Mundipharma, Mylan, Pfizer, Roche, Sandoz Sublimity, Takeda, TiGenix, UCB Pharma, and Vifor Pharma, Speakers bureau of: AbbVie, Amgen, Ferring Pharmaceuticals, Gilead Sciences, Janssen, Mylan, Pfizer, and Takeda, A. Dignass Consultant of: AbbVie, Abivax, Amgen, Arena Pharmaceuticals, Bristol Myers Squibb (Celgene), Celltrion, Dr. Falk Pharma, Eli Lilly and Company, Ferring Pharmaceuticals, Fresenius Kabi, Galapagos, Gilead Sciences, Janssen, Merck Sharp & Dohme, Novartis, Pfizer, Pharmacosmos, Roche, Sandoz/Hexal, Takeda, Tillotts Pharma AG, and Vifor Pharma, Speakers bureau of: AbbVie, Amgen, Bristol Myers Squibb, Dr. Falk Pharma, Ferring Pharmaceuticals, Galapagos, High5Md, Janssen, Materia, Merck Sharp & Dohme, Pfizer, Sandoz, Takeda, Tillotts Pharma AG, and Vifor Pharma, K. Matsuoka Grant / Research support from: AbbVie, EA Pharma, JIMRO, Kissei Pharmaceutical, Kyowa Kyorin, Mitsubishi Tanabe, Mochida Pharmaceutical, and Zeria Pharmaceutical Nippon, Speakers bureau of: AbbVie, EA Pharma, JIMRO, Kissei Pharmaceutical, Kyowa Kyorin, Mitsubishi Tanabe, Mochida Pharmaceutical, Takeda, and Zeria Pharmaceutical Nippon, M. Ferrante Grant / Research support from: AbbVie, Amgen, Biogen, Janssen Cilag, Pfizer, Takeda, and Viatris, Consultant of: AbbVie, Boehringer Ingelheim, Celltrion, Eli Lilly and Company, Janssen Cilag, Medtronic, Merck Sharp & Dohme, Pfizer, Regeneron, Sandoz, Takeda, and Thermo Fisher Scientific, Speakers bureau of: AbbVie, Amgen, Biogen, Boehringer Ingelheim, Celltrion, Dr. Falk Pharma, Eli Lilly and Company, Ferring Pharmaceuticals, Janssen, Lamepro, Medtronic, Merck Sharp & Dohme, Mylan, Pfizer, Samsung Bioepis, Sandoz, Takeda, and Thermo Fisher Scientific, M. Long Consultant of: AbbVie, Bristol Myers Squibb, Calibr, Eli Lilly and Company, Genentech, Janssen, Pfizer, Prometheus Biosciences, Roche, Takeda, TARGET PharmaSolutions, and Theravance Biopharma, I. Redondo Employee of: Eli Lilly and Company, T. Gibble Employee of: Eli Lilly and Company, R. Moses Employee of: Eli Lilly and Company, N. Morris Employee of: Eli Lilly and Company, X. Li Employee of: Eli Lilly and Company, C. Milch Employee of: former employee, was employed at Eli Lilly and Company at the time of study, M. Abreu Grant / Research support from: Pfizer, Prometheus Biosciences, and Takeda, Consultant of: AbbVie, Arena Pharmaceuticals, Bristol Myers Squibb, Eli Lilly and Company, Gilead Sciences, Janssen, Microba Life Sciences, Prometheus Biosciences, UCB Pharma, and WebMD, Speakers bureau of: Alimentiv, Intellisphere LLC (HCP Live Institutional Perspectives in GI), Janssen, Prime CME, and Takeda, J. Jones: None Declared

KDM5A Inhibits Antitumor Immune Responses Through Downregulation of the Antigen-Presentation Pathway in Ovarian Cancer

The extent to which effector CD8+ T cells infiltrate into tumors is one of the major predictors of clinical outcome for patients with epithelial ovarian cancer (EOC). Immune cell infiltration into EOC is a complex process that could be affected by the epigenetic makeup of the tumor. Here, we have demonstrated that a lysine 4 histone H3 (H3K4) demethylase, (lysine-specific demethylase 5A; KDM5A) impairs EOC infiltration by immune cells and inhibits antitumor immune responses. Mechanistically, we found that KDM5A silenced genes involved in the antigen processing and presentation pathway. KDM5A inhibition restored the expression of genes involved in the antigen-presentation pathway in vitro and promoted antitumor immune responses mediated by CD8+ T cells in vivo in a syngeneic EOC mouse model. A negative correlation between expression of KDM5A and genes involved in the antigen processing and presentation pathway such as HLA-A and HLA-B was observed in the majority of cancer types. In summary, our results establish KDM5A as a regulator of CD8+ T-cell infiltration of tumors and demonstrate that KDM5A inhibition may provide a novel therapeutic strategy to boost antitumor immune responses.

KLF17 empowers TGF-β/Smad signaling by targeting Smad3-dependent pathway to suppress tumor growth and metastasis during cancer progression

Inhibition of tumor suppressive signaling is linked to cancer progression, metastasis and epithelial–mesenchymal transition (EMT). Transforming growth factor-β1 (TGF-β)/Smad signaling plays an important role in tumor suppression. Kruppel-like-factor 17 (KLF17) is a negative regulator of metastasis and EMT. However, underlying mechanisms leading to tumor suppressive and anti-metastatic function of KLF17 still remains unknown. Here, we show that KLF17 plays an integral role in potentiating TGF-β/Smad signaling via Smad3-dependent pathway to suppress tumor progression. Intriguingly, TGF-β/Smad3 signaling induces KLF17 expression, generating a positive feedback loop. TGF-β/Smad3–KLF17 loop is critical for anti-metastasis and tumor inhibition in cancer cells. Mechanistically, silencing KLF17 reduced Smad3–DNA complex formation on Smad binding element (SBE) and affects the expression of TGF-β/Smad target genes. Moreover, KLF17 alters Smad3 binding pattern on chromatin. KLF17 regulates TGF-β target genes that are Smad3-dependent. Smad3 and KLF17 physically interact with each other via KLF17 responsive elements/SBE region. Intriguingly, TGF-β stimulates the recruitment of KLF17 on chromatin to subsets of metastasis-associated genes. Functionally, depletion of KLF17 enhanced tumorigenic features in cancer cells. KLF17 is critical for full cytostatic function of TGF-β/Smad signaling. Clinically, KLF17 expression significantly decreases during advance HCC. KLF17 shows positive correlation with Smad3 levels in cancer samples. Our data shows that enhance KLF17 activity has important therapeutic implications for targeted-therapies aimed at TGF-β/Smad3 pathway. These findings define novel mechanism by which TGF-β/Smad–KLF17 pathway mutually affect each other during cancer metastasis, provide a new model of regulation of TGF-β/Smad signaling by KLF17 and defines new insights into anti-metastatic function of KLF17.

Second-trimester intra-abdominal bowel dilation in fetuses with gastroschisis predicts neonatal bowel atresia

OBJECTIVE

To determine in fetuses with gastroschisis the association between intra-abdominal bowel dilation in the second trimester and neonatal bowel atresia.

METHODS

We reviewed ultrasound and medical records of fetuses with gastroschisis from January 1998 to August 2004. Fetuses with intra-abdominal bowel dilation in the second trimester were identified and followed into the neonatal period.

RESULTS

We identified 58 mother-infant pairs showing fetal gastroschisis, with at least one prenatal ultrasound at our hospital and which were delivered there, or were transported there as newborns. Forty-eight of the 58 fetuses had no intra-abdominal bowel dilation and none of these neonates had bowel atresia. Ten of the 58 fetuses had intra-abdominal bowel dilation and all had bowel atresia at birth (P<0.0001). In eight cases in which ultrasound was performed at <25 weeks' gestation, intra-abdominal bowel dilation was already present.

CONCLUSION

Intra-abdominal bowel dilation in the second trimester predicts neonatal bowel atresia in fetuses with gastroschisis.

Repaglinide in combination therapy

Type 2 diabetes mellitus (T2DM) is a progressive disorder requiring increasingly aggressive treatment to achieve and maintain target blood glucose concentrations in the presence of deteriorating insulin secretion and increasing insulin resistance. Diet and lifestyle modification are often sufficient initially; however, most patients eventually require pharmacological intervention. With disease progression, monotherapy becomes less effective, so combination therapy is required, using drugs with complementary modes of action to maximise glycaemic control. The prandial glucose regulator repaglinide has been studied in combination with metformin (an inhibitor of hepatic glucose production), neutral protamine Hagedorn (NPH)-insulin (which has a long duration of effect, but at the risk of early hypoglycaemia and late hyperglycaemia in the dosing interval) and three thiazolidinediones (TZDs--troglitazone, rosiglitazone and pioglitazone, which stimulate nuclear receptors to increase insulin sensitivity and reduce insulin resistance) in patients whose diabetes was inadequately controlled by previous monotherapy or combination therapy. The combination of repaglinide and metformin resulted in reduced fasting plasma glucose concentrations (by 2.2 mmol/l) and HbA1c (by 1.4%). Combination therapy with repaglinide and bedtime NPH-insulin resulted in reductions in fasting plasma glucose (by 5.4 mmol/l) and HbA1c (by 0.7%). The combination of repaglinide and each TZD also resulted in consistent decreases in fasting plasma glucose concentrations and HbA1c. No severe hypoglycaemic episodes were reported in the three studies. In conclusion, repaglinide has additive, and often synergistic, effects on glycaemic control when given in combination regimens and should be a valuable option in the management of patients with T2DM.

The putative collagen binding peptide hastens periodontal ligament cell attachment to bone replacement graft materials

BACKGROUND

Bone replacement graft (BRG) materials are often used to treat periodontal defects, to promote cellular invasion, and to encourage bone regrowth. Periodontal ligament fibroblasts (PDLF) incorporate these materials and form the basis of the renewed connection between the existing and newly formed alveolar bone and the tooth surface. A peptide (P-15) that mimics the putative cell-binding domain of collagen has been reported to promote dermal fibroblast attachment and proliferation.

METHODS

PDLF were quantitatively examined for their ability to adhere to a variety of BRG materials fluorometrically. In addition, scanning electron microscopy was used to examine the changes in morphology exhibited by these cells as they attached and spread on several BRG materials. Finally, BRG materials containing the P-15 peptide were quantitatively examined for their ability to promote PDLF attachment and proliferation.

RESULTS

Freeze-dried allograft bone supports greater PDLF attachment than does several xenograft and alloplastic anorganic bone replacement materials. An anorganic BRG material containing the P-15 peptide promoted more rapid cell attachment and spreading than a similar anorganic BRG material lacking this peptide. Finally, none of the BRG materials examined promoted PDLF proliferation.

CONCLUSIONS

Our data indicate that the addition of the P-15 peptide increases the rapidity of PDLF attachment to xenogeneic bone replacement materials. This increase in the rate of attachment may have clinical significance in the context of the dynamic regulation of cell attachment during periodontal regeneration. However, this peptide does not promote an increase in stable cell attachment or proliferation in vitro.

Gingival, dermal, and periodontal ligament fibroblasts express different extracellular matrix receptors

BACKGROUND

Fibroblasts are the predominant cells of the periodontal ligament and the gingiva and have important roles in the function and regeneration of the tooth support apparatus. The goal of this study was to investigate the possible differences in the adhesion properties and expression of extracellular matrix (ECM) receptors among different fibroblast populations.

METHODS

The adhesion of gingival (GF), dermal (DF), and periodontal ligament fibroblast (PDLF) cultures to ECM proteins (fibronectin, laminin, vitronectin, RGD peptide, collagen type I, and collagen type IV) adsorbed to tissue culture plastic was evaluated fluorometrically. Quantitative reverse transcription-polymerase chain reactions (RT-PCR) were performed using primers specific for 19 integrin subunits to quantify ECM receptor transcript expression.

RESULTS

Our data demonstrated that GF and PDLF adhere to vitronectin and collagen types I and IV more avidly than do DF. PDLF adhered well to laminin, whereas GF and DF did not. Quantitation of integrin expression demonstrated that the different fibroblast types expressed different integrin transcripts, further demonstrating their innate differences.

CONCLUSIONS

The 3 fibroblast types studied behave differently and expressed different ECM receptors. However, gingival fibroblasts and periodontal ligament fibroblasts are more similar in their attachment and integrin expression than either is to dermal fibroblasts. Therefore, experiments using DF will not necessarily be valid for oral tissues.

Positional cloning of a novel Fanconi anemia gene, FANCD2

Fanconi anemia (FA) is a genetic disease with birth defects, bone marrow failure, and cancer susceptibility. To date, genes for five of the seven known complementation groups have been cloned. Complementation group D is heterogeneous, consisting of two distinct genes, FANCD1 and FANCD2. Here we report the positional cloning of FANCD2. The gene consists of 44 exons, encodes a novel 1451 amino acid nuclear protein, and has two protein isoforms. Similar to other FA proteins, the FANCD2 protein has no known functional domains, but unlike other known FA genes, FANCD2 is highly conserved in A. thaliana, C. elegans, and Drosophila. Retroviral transduction of the cloned FANCD2 cDNA into FA-D2 cells resulted in functional complementation of MMC sensitivity.

A review of clinical experience with the prandial glucose regulator, repaglinide, in the treatment of type 2 diabetes

Repaglinide is a novel insulin secretagogue that was developed as a prandial glucose regulator for the treatment of people with Type 2 diabetes mellitus. It is used flexibly, taken prior to meals, in order to limit subsequent postprandial blood glucose excursions as well as the dependent basal blood glucose concentration. In theory, the pharmacological profile of repaglinide is well suited for this role. Taken at mealtimes, its relatively rapid-onset and short-duration of action counteract a fundamental pathophysiological aspect of this disease: attenuation of the prandial insulin response. The predominantly hepatic elimination profile and a lack of drug-drug interactions with repaglinide are also properties well suited for patients with Type 2 diabetes. Importantly, the pharmacokinetic properties of repaglinide, are expected to reduce the risk of hypoglycaemia in comparison to the conventional insulin secretagogues (sulphonylureas). A reduced risk of hypoglycaemia carries the advantage that patients are not obliged to consume meals at regular intervals supplemented by snacks, so caloric restriction is feasible and lifestyle not compromised. These theoretical advantages have now been largely borne-out by clinical studies and empirical experience. Placebo-controlled studies have consistently demonstrated the antidiabetic efficacy of repaglinide, with improvements having been shown in all indicators of glycaemic control. Double-blind, active-comparator studies have shown repaglinide to have an antidiabetic efficacy that is at least equivalent to sulphonylureas, even when food intake and dosing intervals were controlled according to the requirements of sulphonylureas. Pooled data from these studies have shown that the risk of severe hypoglycaemia is reduced by 60% (p = 0.03) when repaglinide is used in preference to sulphonylureas. There is also evidence that the blood glucose threshold at which symptoms of hypoglycaemia are perceived by patients may be better preserved during treatment with repaglinide than with sulphonylureas. Studies examining flexible prandial dosing with repaglinide have shown that good glycaemic control and a low risk of hypoglycaemia are achievable goals that are independent of the meal (and, hence, dosing) pattern chosen by the patient. Furthermore, when used in this way, repaglinide has not been associated with weight gain. In combination therapy, repaglinide has been shown to act in synergy with both metformin and troglitazone. The possibility of a 'new' basal-bolus regimen combining repaglinide and exogenous (neutral protamine hagedorn) NPH insulin strategy has also been investigated.

[Repaglinide in combination therapy in type 2 diabetes]

In addition to dietary and lifestyle changes, standing as the cornerstone of type 2 diabetes care, pharmacological treatments, whether as single or multidrug patterns, are often necessary for an efficient blood glucose control. Besides insulin, four different oral antidiabetic drug categories are available, each of them acting through different and potentially synergistic ways. Oral antidiabetic drugs include: 1) biguanides acting through the reduction of hepatic glucose production and are most efficient in obese patients; 2) alpha-glucosidase inhibitors delaying carbohydrate intestinal absorption; 3) thiazolidinediones or "glitazones", acting as insulin sensitizers; 4) insulin secretion enhancers, mainly including sulfonylureas, which increase insulin secretion and are being credited by a long clinical usage; these are now joined by the new generation of insulin secretion enhancers, led by repaglinide, which can mimic the physiological insulin secretion profile by a specific stimulatory effect on beta-cells characterized by its fast onset and short half-life. Obviously, the combination of these different antidiabetic drugs, by targetting different synergistic and additive pathways, can help to further improve blood glucose.

Repaglinide in combination therapy with metformin in Type 2 diabetes

Results are presented of a double-blind, Australian multicentre study of the efficacy and safety of adjunctive repaglinide in patients with Type 2 diabetes who were controlled inadequately on metformin monotherapy. Patients had to have been on metformin for at least 6 months and to have glycated haemoglobin (HbA1c) levels of more than 7.1%. Patients were randomized to one of three treatment regimens: metformin plus placebo (MET, n = 27), repaglinide plus placebo (REP, n = 29) and metformin plus repaglinide (MET/REP, n = 27). The metformin dose remained unchanged from the prestudy dose, whereas repaglinide was titrated from 0.5 mg to 4.0 mg preprandially, depending on fasting capillary blood glucose concentration. Maintenance treatment was continued for 3 months. In the MET and REP groups, the HbA1c level decreased from 8.6% to 8.3% and from 8.6% to 8.2%, respectively; in the MET/REP group, HbA1c decreased from 8.3% to 6.9% (p < 0.001 vs. baseline; p < 0.05 vs. each monotherapy group). Overall, 59% of patients in the MET/REP group achieved a HbA1c level of less than 7.1% by the end of the study, compared with 20% and 22% in the MET and REP groups, respectively. No serious adverse events occurred that were considered to be related to study medication. Mild symptoms of hypoglycaemia were seen in the REP and MET/REP groups, in many cases during the titration phase. The combination of repaglinide with metformin was safe and well tolerated and produced a greater improvement in glycaemic control than that seen by the sum of the changes with the two agents alone.

The converging roads of HIM and managed care

The authors explore the definition of managed care and how the health information manager's skills apply to a managed care setting. In addition, HIM professionals who have made the transition to the managed care setting share their experiences.

Effect of repaglinide addition to metformin monotherapy on glycemic control in patients with type 2 diabetes

OBJECTIVE

To compare the effect of repaglinide in combination with metformin with monotherapy of each drug on glycemic control in patients with type 2 diabetes.

RESEARCH DESIGN AND METHODS

A total of 83 patients with type 2 diabetes who had inadequate glycemic control (HbA1c > 7.1%) when receiving the antidiabetic agent metformin were enrolled in this multicenter, double-blind trial. Subjects were randomized to continue with their prestudy dose of metformin (n = 27), to continue with their prestudy dose of metformin with the addition of repaglinide (n = 27), or to receive repaglinide alone (n = 29). For patients receiving repaglinide, the optimal dose was determined during a 4- to 8-week titration and continued for a 3-month maintenance period.

RESULTS

In subjects receiving combined therapy, HbA1c was reduced by 1.4 +/- 0.2%, from 8.3 to 6.9% (P = 0.0016) and fasting plasma glucose by 2.2 mmol/l (P = 0.0003). No significant changes were observed in subjects treated with either repaglinide or metformin monotherapy in HbA1c (0.4 and 0.3% decrease, respectively) or fasting plasma glucose (0.5 mmol/l increase and 0.3 mmol/l decrease respectively). Subjects receiving repaglinide either alone or in combination with metformin, had an increase in fasting levels of insulin between baseline and the end of the trial of 4.04 +/- 1.56 and 4.23 +/- 1.50 mU/l, respectively (P < 0.02). Gastrointestinal adverse events were common in the metformin group. An increase in body weight occurred in the repaglinide and combined therapy groups (2.4 +/- 0.5 and 3.0 +/- 0.5 kg, respectively; P < 0.05).

CONCLUSIONS

Combined metformin and repaglinide therapy resulted in superior glycemic control compared with repaglinide or metformin monotherapy in patients with type 2 diabetes whose glycemia had not been well controlled on metformin alone. Repaglinide monotherapy was as effective as metformin monotherapy.

The accuracy of home glucose meters for the glucose range anticipated in pregnancy

Home glucose meters are used almost universally for the management of pregnant women with diabetes. However, the degree of accuracy of meters in general and particularly for the lower glucose range, is questionable. Six of the most commonly used meters in Australia were evaluated for analytical accuracy for glucose levels < 8.0 mmol/L--a level below which many important clinical management decisions are made. Two meters, Elite and Precision QID, cannot be recommended. The other 4 meters, Glucometer 3, Reflolux S, Alpha and Advantage produced results with a higher degree of analytical accuracy. Of the meters tested, the Accutrend Alpha had the highest proportion of results within 5% and 10% of a laboratory reference method, the lowest bias with the Altman Bland method of comparison, and is recommended for use in pregnancy. No meter approached the analytical accuracy goal recommended by the American Diabetes Association. Manufacturers should be encouraged to develop or adapt systems for use in pregnancy.

Predominance of a maternal history of diabetes for patients with non-insulin-dependent diabetes mellitus. Implications for the intrauterine transmission of diabetes

In Europid populations, patients with non-insulin-dependent diabetes mellitus (NIDDM) are more than twice as likely to have a mother than a father with diabetes. We have examined this aspect in an Australian population. For this purpose records of 1,000 consecutive patients with NIDDM were reviewed. A history of diabetes was present in 193 mothers (19.3%) and in only 86 fathers (8.6%) (p < 0.0001). The predominance of maternal history of diabetes in patients with NIDDM is suggestive of a maternal transmission of this disorder. This metabolic tendency may develop due to an adverse intrauterine environment in women with undiagnosed gestational diabetes mellitus.

Gestational diabetes mellitus; resource utilization and costs of diagnosis and treatment

The recommendation to test every woman for gestational diabetes mellitus (GDM) has a defined cost. The management of women diagnosed with GDM will use additional health resources. This examines the cost and resource utilization of a consecutive group of women diagnosed over a 1-year period. The cost of testing a woman for GDM is around $10.00 with slight variations depending on the testing procedure. The annual cost of testing in NSW would be less than 1 million dollars. Women diagnosed with GDM used the resources of a diabetes education centre for an average of 2.8 hours and attended for 3.4 (2.3) medical visits. Insulin was required by 18.7% of the women for 9.7 (4.7) weeks using 47.7 (21.2) units each day. Testing women for GDM is a low-cost item. Managing a woman diagnosed with GDM may cost several hundred dollars. Cost reductions could be made by reducing the amount of insulin used and by avoiding hospitalization.

The metabolic profile of glucose tolerant women who have had large for gestational age babies

The possibility has been raised that women who have had large for gestational age infants, while glucose tolerant during pregnancy by conventional testing, may still have a subtle abnormality of carbohydrate metabolism. We have examined, some time after the completion of a pregnancy, the fasting levels of glucose, insulin and lipids in a group of women, glucose tolerant during pregnancy, who had a large for gestational age infant compared to a very carefully matched control group of women who had an appropriate for gestational age infant. No significant differences were found. These findings suggest that women who have a large for gestational age infant do so for a variety of reasons not related to maternal carbohydrate metabolism.

Vertical impact forces during bench-step aerobics: exercise rate and experience

The purpose of this study was to determine the effects of two bench-step exercise speeds on vertical impact forces and to explore this variable between novices, and instructors. 12 women (mean age 24 yr.) randomly performed 8-min. protocols of the "basic" bench-stepping technique and a more advanced "travel" technique at 30 and 33 cycles.min.-1. Analysis showed that the faster exercise rate yielded significantly higher vertical impact forces on a reference (B-8) step height (20.3 cm). At 33 cycles.min.-1, the instructors, and novices' responses were both higher than those at 30 cycles.min.-1. The mean peak vertical impact force ranged from 1.54 times the body weight for the novice group at 30 cycles.min.-1 to 1.87 times the body weight for instructors at 33 cycles.min.-1. A comparison of the groups' force curves showed a distinctive pattern in the loading of the impact forces. Specifically, the instructors consistently produced a transitory decrement in force prior to attaining peak force. In addition, the novices exhibited nonuniform increases in the production of vertical impact force across other step heights at the faster (33 cycles.min.-1) speed. Thus, experience with bench-step exercise may afford an ability to make uniform and force-absorbing adjustments in the resultant vertical impact forces at increased speeds.

Some sociopsychological and political perspectives of the meaning of the Holocaust: a view from Israel

On the background of some psychological, social and political reactions to the Holocaust over the last 40 years, this paper focuses on the meaning of the Holocaust as it is woven into the social and political fabric of Israel today. The Palestinian-Israeli conflict receives special emphasis in this context. Through a psychoanalytic lens, the motivations leading both to the denial of the Holocaust and its usage in different areas of political life is examined; the usage taking place on different levels on the continuum conscious-unconscious. Such usage as well as its consequences encourage a holding on to rigid positions and to the past; this comes at the expense of dealing effectively with the present. Such patterns of behavior are in this way social mechanisms analogous to the well-known unconscious psychological mechanisms of defense. They are akin to other psychological phenomena, such as the repetition compulsion and the mechanism of psychological deployment. Clinical and social illustrations of these phenomena are given.

Free fatty acids and gestational diabetes mellitus

Dyslipidaemia is a common finding in the syndrome of gestational diabetes mellitus (GDM). Free fatty acids (FFA) can cause insulin resistance and have a toxic effect on beta cell function. GDM is a syndrome due to insulin resistance and the purpose of this study was to examine FFA levels in pregnancy. For this purpose samples were taken from 44 consecutive women with GDM and 36 consecutive controls. The women with GDM had similar levels of insulin, triglycerides and total cholesterol to the controls but a significant elevation in FFA; 0.70 (0.33) mmol/L versus 0.29 (0.12) mmol/L (p < 0.0001).

Gestational diabetes: do all women need to be tested?

The results of glucose tolerance testing in 1,185 consecutive women were examined with respect to historical risk factors for gestational diabetes mellitus (GDM). GDM was present in 79 of 1,185 (6.7%) of the women. GDM was present in 8.5% of women aged > or = 30 years, in 12.3% of women with a preconception BMI > or = 30 and in 11.6% of women with a family history of diabetes in a first degree relation. A combination of one or all of these risk factors predicted GDM in only 48 of 79 (60.8%) cases. GDM was present in 4.8% of women without risk factors. Testing for GDM on the basis of these historical risk factors alone, and using the Australasian Diabetes in Pregnancy Society (ADIPS) criteria for diagnosis, would miss more than one-third of all cases. This study supports the ADIPS recommendation that there should be universal testing.

Is there a seasonal variation in the incidence of gestational diabetes?

It has been suggested that the incidence of gestational diabetes (GDM) may vary with different seasons of the year. The fasting and 2 h glucose levels after a 75 g glucose tolerance test were therefore examined in 2749 women being tested for GDM and were correlated with the mean temperature at 0900 h by month and by season. The mean monthly temperature ranged from 22.3 degrees C in January to 13.6 degrees C in July. The monthly incidence of GDM ranged from 3.5% (95% CI, 0.7-6.3) in September to 8.7% (4.7-12.7) in November. The seasonal incidence of GDM ranged from 7.4% (5.6-9.2) in autumn to 5.5% (3.5-7.5) in winter. Chi-squared analysis did not suggest a significant association between the proportion of women diagnosed with GDM and either the month (p = 0.47) or the season (p = 0.39). Multiple regression analysis, after correction for maternal age, parity, BMI, and the week of testing revealed a non-significant association between fasting glucose and monthly temperature (p = 0.36) and an increase in the 2 h glucose of 0.026 mmol l-1 for each increase of 1 degree C in temperature (p = 0.011). In a temperate coastal area of Australia these differences do not appear clinically significant and have not caused a variation in the incidence of GDM with different seasons.

Diabetic control and hypoglycaemia in the Illawarra area of NSW, Australia: a comparison with the DCCT

The level of diabetic control and the number of hypoglycaemic episodes in the intensively treated insulin-dependent diabetes mellitus (IDDM) patients of the Diabetes Control and Complication Trial (DCCT) are a stimulus for other centres to critically examine their results. We examined diabetic control and the number of hypoglycaemic episodes in an unselected group of patients with IDDM diabetes from a population based diabetes register in the Illawarra area of Australia. Eligible patients were insulin dependent, aged 13-39 years, diagnosed for more than 1 year and had had a HbA1c test in the previous 6 months. Better diabetic control was achieved in patients with IDDM, without the need for intensive insulin therapy, than the intensively treated patients of the DCCT with fewer hypoglycaemic events. Before intensive insulin therapy for all patients with IDDM is considered, different models of diabetic healthcare delivery and medical treatment philosophies need to be examined.

Type II diabetes mellitus, congestive heart failure, and zinc metabolism

Zinc status was assessed in patients with type II diabetes mellitus and congestive heart failure (CHF). Three groups of patients were enrolled into the study: Group 1: 15 patients with type II diabetes mellitus and CHF; Group 2: 20 patients with isolated type II diabetes mellitus; and Group 3: nine patients with isolated CHF. Twenty-four-hour urine was measured for creatinine, protein, and zinc, and blood was drawn for creatinine, proteins, liver enzymes, hemoglobin A1c, and zinc. Insulin treatment and hemoglobin A1c were comparable in the diabetic patients of groups 1 and 2, but group 1 was also treated with captopril and diuretics like the CHF patients of group 3. Plasma zinc levels were statistically similar in all three groups, but urinary zinc excretion (mumol/24 h) and urinary zinc: creatinine (mumol/mmol) ratio were significantly higher in the type II diabetics and CHF group (27.2 +/- 1.5; 1.69 +/- 0.6, respectively) compared to the diabetic patients alone (19.4 +/- 0.76; 0.97 +/- 0.3, respectively) and the CHF patients (9.7 +/- 0.3; 0.62 +/- 0.3, respectively). and the CHF patients (9.7 +/- 0.3; 0.62 +/- 0.3, respectively). Patients with type II diabetes mellitus and CHF were treated with higher doses of captopril than the CHF patients (56.25 +/- 24 mg vs 18.8 +/- 11 mg P < 0.05). Thus, patients with type II diabetes mellitus and CHF excrete larger amounts of zinc, which may eventually lead to zinc deficiency.

Health service utilisation in the public and private sector by patients with diabetes mellitus aged less than 40 years

This paper uses the Illawarra 0-39 years diabetes register to provide a data base of health service utilisation in the public and private sectors. Eligible patients from the register were divided into a 'stable group' comprising children and adults who had had diabetes for more than one year prior to review and a 'newly diagnosed' group who were followed for one year after diagnosis. The records of inpatient and selected outpatient services at public hospitals as well as visits to general practitioners, paediatricians and physicians were considered. Less than half of all 'newly diagnosed' patients were admitted to hospital for stabilisation and none required readmission in the 12 month review period. Less than one fifth of all 'stable' patients were admitted to hospital during the year. General practitioners were the most frequently used health resource being attended by 31/38 (82%) 'stable children', 122/133 (92%) 'stable adults' and 25/25 (100%) 'newly diagnosed patients'. Public hospital Accident and Emergency Services were the least used health facility being frequented by only 9/38 (24%), 23/133 (17%) and 7/25 (28%) respectively.

CEO evaluation--fairness above all. Interview by Karen Gardner

How effectively the hospital governing board communicates with and evaluates its CEO may have a direct impact on CEO turnover. Board chairman Richard Moses of Tuomey Hospital, Sumter, SC, describes the process for conducting a fair and meaningful evaluation.

Xenograft rejection of class I-expressing transgenic skin is CD4-dependent and CD8-independent

B10.PD1 mice are transgenic animals expressing a class I MHC antigen of pigs. B10.PD1 skin graft survival on B6 mice was prolonged by anti-CD4 antibody treatment in vivo but not by anti-CD8 treatment. These results suggest: (1) that the defect in cell-mediated recognition of xenografts involves an interaction with the xeno-MHC antigens themselves and not with the cells which express them; (2) that antigen processing and presentation of xeno-antigens on responder-type APCs is required in vivo; and (3) that CD8-independent, possibly noncytotoxic, mechanisms of xenograft rejection may exist.