Stratification of Tamoxifen Synergistic Combinations for the Treatment of ER+ Breast Cancer

Breast cancer alone accounts for the majority of cancer deaths among women, with the most commonly diagnosed subtype being estrogen receptor positive (ER+). Survival has greatly improved for patients with ER+ breast cancer, due in part to the development of antiestrogen compounds, such as tamoxifen. While treatment of the primary disease is often successful, as many as 30% of patients will experience recurrence and metastasis, mainly due to developed endocrine therapy resistance. In this study, we discovered two tamoxifen combination therapies, with simeprevir and VX-680, that reduce the tumor burden in animal models of ER+ breast cancer more than either compound or tamoxifen alone. Additionally, these tamoxifen combinations reduced the expression of HER2, a hallmark of tamoxifen treatment, which can facilitate acquisition of a treatment-resistant phenotype. These combinations could provide clinical benefit by potentiating tamoxifen treatment in ER+ breast cancer.

Investigating the use of local nerve blocks and general anaesthesia in reducing pain during and after disbudding procedure in goat kids

The aim of this study was to compare the pain responses (as measured by noise and movement) during administration of local anaesthetic and during and after disbudding in goat kids. Eighty, seven- to ten-day-old, Saanen goat kids from one farm were enrolled and randomly assigned to one of four different methods of pain relief. Twenty kids had local anaesthetic (LA) applied at two sites per horn bud (LA group), 20 kids had LA applied to the two locations using a jet injector (JI group) and 20 kids were given a general anaesthetic (GA) using a combination of 0.02 mg/kg medetomidine and 2 mg/kg ketamine followed by a horn bud block applied as per the LA group (GA group). The remaining 20 kids had no treatment other than meloxicam (control group). Although responses between goat kids and at different time periods were variable, in comparison to the control group, GA eliminated the responses associated with injection of lignocaine and the responses during the period of disbudding, and provided a reduction in head scratches and shakes across multiple time periods.

Discovering Synergistic Compounds with BYL-719 in PI3K Overactivated Basal-like PDXs

Basal-like triple-negative breast cancer (TNBC) tumor cells are difficult to eliminate due to resistance mechanisms that promote survival. While this breast cancer subtype has low PIK3CA mutation rates when compared to estrogen receptor-positive (ER+) breast cancers, most basal-like TNBCs have an overactive PI3K pathway due to gene amplification or high gene expression. BYL-719 is a PIK3CA inhibitor that has been found to have low drug-drug interactions, which increases the likelihood that it could be useful for combinatorial therapy. Alpelisib (BYL-719) with fulvestrant was recently approved for treating ER+ breast cancer patients whose cancer had developed resistance to ER-targeting therapy. In these studies, a set of basal-like patient-derived xenograft (PDX) models was transcriptionally defined with bulk and single-cell RNA-sequencing and clinically actionable mutation profiles defined with Oncomine mutational profiling. This information was overlaid onto therapeutic drug screening results. BYL-719-based, synergistic two-drug combinations were identified with 20 different compounds, including everolimus, afatinib, and dronedarone, which were also found to be effective at minimizing tumor growth. These data support the use of these drug combinations towards cancers with activating PIK3CA mutations/gene amplifications or PTEN deficient/PI3K overactive pathways.

Assessments of Somatic Variant Classification Using the Association for Molecular Pathology/American Society of Clinical Oncology/College of American Pathologists Guidelines: A Report from the Association for Molecular Pathology

To assess the clinical implementation of the 2017 Standards and Guidelines for the Interpretation and Reporting of Sequence Variants in Cancer: A Joint Consensus Recommendation of the Association for Molecular Pathology, American Society of Clinical Oncology, and College of American Pathologists, identify content that may result in classification inconsistencies, and evaluate implementation barriers, an Association for Molecular Pathology Working Group conducted variant interpretation challenges and a guideline implementation survey. A total of 134 participants participated in the variant interpretation challenges, consisting of 11 variants in four cancer cases. Results demonstrate 86% (range, 54% to 94%) of the respondents correctly classified clinically significant variants, variants of uncertain significance, and benign/likely benign variants; however, only 59% (range, 39% to 84%) of responses agreed with the working group's consensus intended responses regarding both tiers and categories of clinical significance. In the implementation survey, 71% (157/220) of respondents have implemented the 2017 guidelines for variant classification and reporting either with or without modifications. Collectively, this study demonstrates that, although they may not yet be optimized, the 2017 guideline recommendations are being adopted for standardized somatic variant classification. The working group identified significant areas for future guideline improvement, including the need for a more granular and comprehensive classification system and education resources to meet the growing needs of both laboratory professionals and medical oncologists.

The basics of commonly used molecular techniques for diagnosis, and application of molecular testing in cytology

Molecular diagnostics has expanded to become the standard of care for a variety of solid tumor types. With limited diagnostic material, it is often desirable to use cytological preparations to provide rapid and accurate molecular results. This review covers important pre-analytic considerations and limitations, and a description of common techniques that the modern cytopathologist should understand when ordering and interpreting molecular tests in practice.

Severe Graft-Versus-Host Disease Following Solid-Organ Transplant Confirmed by Chimerism Studies and Cytogenetic Analyses

Graft-versus-host disease is an uncommon complication of solid-organ transplant and is associated with a high rate of mortality. Here, we describe a female patient with primary biliary cholangitis who developed graft-versus-host disease following an orthotopic liver and renal allotransplant from a deceased male donor. Systemic donor lymphoid chimerism is one of several important findings to confirm a diagnosis of graft-versus-host disease after solid-organ transplant, along with clinical and histologic findings. In this case, cytogenetic analyses and chimerism studies performed on blood, blood components, and bone marrow specimens obtained at several timepoints supported the diagnosis of graft-versus-host disease and demonstrated sustained near-complete donor engraftment of the lymphoid compartment. This case report illustrates the utility of chimerism testing to rapidly diagnose this serious condition in patients who have received a solid-organ transplant.

Comparison of Three Anaesthetic Options to Reduce Acute Pain Response in Kid Goats

Three options for anesthetizing the skin around the horn bud of dairy goat kids were explored. Forty-five <10-day-old Saanen goat kids from were randomly split into five treatment groups (topical anesthetic cream (TA), vapocoolant spray (VS), local anesthetic applied by jet injector (JI), control - no treatment but painful stimulus applied (C), sham - no treatment and touching sites with a finger. The painful stimulus was multiple needle pricks on the skin around the horn bud. The outcome variables measured were heart rate movement, and vocalization during treatment application and administration of a painful stimulus around the horn bud. Heart rates were greater during application of a VS compared to TA.Neither the TA nor the VS appeared to have any effect on the response to the painful stimulus. Kids in the JI group had a 96% reduced odds of expressing a marked pain response in comparison to TA group and an 83% reduction in the odds of a high movement grade during a painful procedure in comparison to the combined results of the other three treatment groups.

A PRACTICAL EFFECT OF THE RECENT O16 CROSS SECTION AND MUBAR UNCERTAINTIES

With the recent release of ENDF/B VIII.0 data, additional covariance data was provided for many isotopes, including O16. The detail of elastic scattering and mubar covariance data for O16 increased dramatically between ENDF/B VII.1 and ENDF/B VIII.0. This new covariance data has been processed with NJOY2016 and investigation has begun on the effects of these new uncertainty data. The uncertainties are applied to multi-group scattering cross sections and P1 Legendre components in deterministic neutron transport.

A simple but typical application of shielding fission neutrons with concrete has been used to assess the practical effects of the new covariance data for O16. A somewhat surprising result is that the mubar uncertainty can have a significant effect on the calculated shielding and criticality results.

HNRNPH1-related syndromic intellectual disability: Seven additional cases suggestive of a distinct syndromic neurodevelopmental syndrome

Pathogenic variants in HNRNPH1 were first reported in 2018. The reported individual, a 13 year old boy with a c.616C>T (p.R206W) variant in the HNRNPH1 gene, was noted to have overlapping symptoms with those observed in HNRNPH2-related X-linked intellectual disability, Bain type (MRXSB), specifically intellectual disability and dysmorphic features. While HNRNPH1 variants were initially proposed to represent an autosomal cause of MRXSB, we report an additional seven cases which identify phenotypic differences from MRXSB. Patients with HNRNPH1 pathogenic variants diagnosed via WES were identified using clinical networks and GeneMatcher. Features unique to individuals with HNRNPH1 variants include distinctive dysmorphic facial features; an increased incidence of congenital anomalies including cranial and brain abnormalities, genitourinary malformations, and palate abnormalities; increased incidence of ophthalmologic abnormalities; and a decreased incidence of epilepsy and cardiac defects compared to those with MRXSB. This suggests that pathogenic variants in HNRNPH1 result in a related, but distinct syndromic cause of intellectual disability from MRXSB, which we refer to as HNRNPH1-related syndromic intellectual disability.

Feeding synthetic zeolite to transition dairy cows alters neutrophil gene expression

Synthetic zeolites are used to control the availability of dietary minerals (e.g., Ca, Mg, and P) in dairy cows. Due to calcium demand increasing with lactation onset, most cows become hypocalcemic immediately postpartum, which likely contributes to poorer immune function because calcium is important for immune cell signaling. To overcome postpartum hypocalcemia, we fed transition cows synthetic zeolite A (sodium aluminosilicate) precalving and hypothesized that it would alter calcium and thus neutrophil function during the transition period. Multiparous Holstein-Friesian cows in late gestation were randomly allocated to an untreated control group (n = 10) or a treatment group in which each cow received 500 g of zeolite A daily (n = 10) for 14 d prior to the expected calving date (actual duration = 17 ± 3 d prepartum). The cows grazed pasture, and each was supplemented with 2 kg/d of maize silage (dry matter basis), with or without zeolite, until calving. Blood samples for neutrophil isolation and analysis of plasma indicators of mineral status, energy status, liver function, and inflammation were collected pretreatment (covariate; d -19); on d -14 and -7 precalving; on the day of calving (d 0); and on d 1, 4, 7, and 28 postcalving. Neutrophils were isolated and gene expression was analyzed using microfluidic gene expression arrays. Neutrophil respiratory burst was assessed using stimulation with phorbol 12-myristate 13-acetate and flow cytometry. Plasma calcium and phosphorus revealed a treatment by time interaction; cows offered zeolite had greater plasma calcium concentrations at d 0, 1, and 4 postcalving and plasma phosphorus concentrations were lower in zeolite-treated cows during the precalving period until d 1 postcalving compared with control animals. Zeolite treatment downregulated neutrophil gene expression of CXCR4 and S100A8 and tended to lower gene expression for other immune mediators (CXCR1, IFNG, S100A12, and S100A9) compared with the control. Zeolite treatment did not affect neutrophil respiratory burst or expression of the other genes investigated. Plasma concentrations of cytokine IL-6 were reduced with zeolite treatment, which was most evident immediately postcalving (d 0, 1, and 7). Overall, feeding zeolite precalving had few effects on neutrophil gene expression and function; however, the lower gene expression of neutrophil inflammatory mediators may be due to altered availability of dietary minerals prepartum and indicates that zeolite A may control inflammation during the transition period.

Lynch syndrome-associated ultra-hypermutated pediatric glioblastoma mimicking a constitutional mismatch repair deficiency syndrome

Pediatric glioblastoma multiforme (GBM) has a poor prognosis as a result of recurrence after treatment of surgery and radiochemotherapy. A small subset of pediatric GBMs presenting with an ultra-high tumor mutational burden (TMB) may be sensitive to immune checkpoint inhibition. Here we report a 16-yr-old male with an ultra-hypermutated GBM. After incomplete surgical resection, molecular analysis of the tumor identified unusually high numbers of mutations and intratumor heterogeneity by a hotspot next-generation sequencing (NGS) panel. Further comprehensive molecular profiling identified a TMB of 343 mutations/Mb. An ultra-hypermutation genotype in pediatric GBMs is suggestive of a constitutive mismatch repair deficiency syndrome (CMMRD), which often acquires additional somatic driver mutations in replicating DNA polymerase genes. Tumor sequencing identified two MSH6 nonsense variants, a hotspot POLE mutation and a mutational signature supportive of a germline MMR deficiency with a somatic POLE mutation. However, constitutional testing identified only one nonsense MSH6 variant consistent with a Lynch syndrome diagnosis. This case represents the first confirmed Lynch syndrome case mimicking CMMRD by manifesting as an ultra-hypermutated pediatric GBM, following somatic mutations in MSH6 and POLE These findings permitted the patient's enrollment in an anti-PD-1 clinical trial for children with ultra-hypermutated GBM. Immunotherapy response has resulted in the patient's stable condition for over more than 1 year postdiagnosis.

Implementation of Multicolor Melt Curve Analysis for High-Risk Human Papilloma Virus Detection in Low- and Middle-Income Countries: A Pilot Study for Expanded Cervical Cancer Screening in Honduras

PURPOSE

Cervical cancer is a leading cause of cancer-related mortality in low- and middle-income countries (LMICs) and screening in LMICs is extremely limited. We aimed to implement on-site high-risk human papillomavirus (hrHPV) DNA testing in cohorts of women from an urban factory and from a rural village.

METHODS

A total of 802 women were recruited for this study in partnership with La Liga Contra el Cancer through the establishment of women's health resource fairs at two locations in Honduras: a textile factory (n = 401) in the city of San Pedro Sula and the rural village of El Rosario (n = 401) in Yoro. Participants received a routine cervical examination during which three sterile cytobrushes were used to collect cervical samples for testing. hrHPV genotyping was performed using a hrHPV genotyping assay and a real-time polymerase chain reaction instrument.

RESULTS

hrHPV status across all participants at both sites was 13% hrHPV positive and 67% hrHPV negative. When hrHPV status was compared across all three testing sites, hrHPV-positive rates were approximately equal among the factory (13%), village (12%), and confirmatory testing at Dartmouth-Hitchcock Medical Center (Lebanon, NH; 14%). hrHPV genotype was compared across sites, with HPV16 showing the highest infection rate (15%), followed by HPV59 (12%), and HPV68 (11%). There was a low prevalence of HPV18 observed in both populations compared with the hrHPV-positive population in the United States.

CONCLUSION

In collaboration with oncologists and pathologists from La Liga Contra el Cancer, we were able to provide a continuum of care once health-fair testing was performed. We established a method and implementation plan for hrHPV testing that is sustainable in LMICs.

The impact of variant classification on the clinical management of hereditary cancer syndromes

PURPOSE

The reclassification of genetic variants poses a significant challenge for laboratories and clinicians. Variant review has resulted in the reclassification of variants of unknown significance as well as the reclassification of previously established pathogenic and likely pathogenic variants. These reclassifications have the potential to alter the clinical management of patients with hereditary cancer syndromes.

METHODS

Results were reviewed for 1694 patients seen for hereditary cancer evaluation between August 2012 and May 2017 to determine the frequency and types of variant reclassification. Patients with reclassifications with high potential for impact were monitored for alterations in organ surveillance, prophylactic surgery, and cascade testing.

RESULTS

One hundred forty-two variants were reclassified representing 124/1694 (7.3%) patients; 11.3% of reclassifications (16/142) had a high potential for clinical impact with 94% (15/16) altering clinical management of patients with 56% (9/16) changing multiple areas of management.

CONCLUSION

While reclassifications are rare, the impact on clinical management is profound. In many cases, patients with downgraded pathogenic/likely pathogenic variants had years of unnecessary organ surveillance and underwent unneeded surgical intervention. In addition, cascade testing misidentified those at risk for developing cancers, thereby altering the management across generations. The frequency and types of alterations to clinical management highlight the need for timely variant reclassification.

A Phase II Trial of Dovitinib in BCG-Unresponsive Urothelial Carcinoma with FGFR3 Mutations or Overexpression: Hoosier Cancer Research Network Trial HCRN 12-157

Purpose: To assess the clinical and pharmacodynamic activity of dovitinib in a treatment-resistant, molecularly enriched non-muscle-invasive urothelial carcinoma of the bladder (NMIUC) population.Experimental Design: A multi-site pilot phase II trial was conducted. Key eligibility criteria included the following: Bacillus Calmette-Guerin (BCG)-unresponsive NMIUC (>2 prior intravesical regimens) with increased phosphorylated FGFR3 (pFGFR3) expression by centrally analyzed immunohistochemistry (IHC+) or FGFR3 mutations (Mut+) assessed in a CLIA-licensed laboratory. Patients received oral dovitinib 500 mg daily (5 days on/2 days off). The primary endpoint was 6-month TURBT-confirmed complete response (CR) rate.Results: Between 11/2013 and 10/2014, 13 patients enrolled (10 IHC+ Mut-, 3 IHC+ Mut+). Accrual ended prematurely due to cessation of dovitinib clinical development. Demographics included the following: median age 70 years; 85% male; carcinoma in situ (CIS; 3 patients), Ta/T1 (8 patients), and Ta/T1 + CIS (2 patients); median prior regimens 3. Toxicity was frequent with all patients experiencing at least one grade 3-4 event. Six-month CR rate was 8% (0% in IHC+ Mut-; 33% in IHC+ Mut+). The primary endpoint was not met. Pharmacodynamically active (94-5,812 nmol/L) dovitinib concentrations in urothelial tissue were observed in all evaluable patients. Reductions in pFGFR3 IHC staining were observed post-dovitinib treatment.Conclusions: Dovitinib consistently achieved biologically active concentrations within the urothelium and demonstrated pharmacodynamic pFGFR3 inhibition. These results support systemic administration as a viable approach to clinical trials in patients with NMIUC. Long-term dovitinib administration was not feasible due to frequent toxicity. Absent clinical activity suggests that patient selection by pFGFR3 IHC alone does not enrich for response to FGFR3 kinase inhibitors in urothelial carcinoma. Clin Cancer Res; 23(12); 3003-11. ©2016 AACR.

Detection of CALR Mutation in Clonal and Nonclonal Hematologic Diseases Using Fragment Analysis and Next-Generation Sequencing

OBJECTIVES

To describe three methods used to screen for frameshift mutations in exon 9 of the CALR gene.

METHODS

Genomic DNA from 47 patients was extracted from peripheral blood and bone marrow using the EZ1 DNA Blood Kit (Qiagen, Valencia, CA) and quantified by the Quant-iT PicoGreen dsDNA Assay Kit (Invitrogen, San Diego, CA). After clinical history, cytogenetics, and molecular tests, patients were diagnosed with either clonal or nonclonal hematologic diseases. CALR screening was primarily performed using fragment analysis polymerase chain reaction, then next-generation sequencing and Sanger sequencing.

RESULTS

Among the 18 patients diagnosed with clonal diseases, one had acute myeloid leukemia (positive for trisomy 8), and 17 had myeloproliferative neoplasms (MPNs), including chronic myeloid leukemia (CML), essential thrombocythemia (ET), primary myelofibrosis (PMF), and polycythemia vera (PV). Patients with CML were positive for the BCR-ABL1 fusion. Ten patients were positive for JAK2 (PMF, n = 1; ET, n = 2; PV, n = 7), and three were CALR positive (ET, n = 1; PMF, n = 2). Patients diagnosed with a nonclonal disease were negative for JAK2, BCR-ABL, and CALR mutations.

CONCLUSIONS

Screening for CALR mutations is essential in BCR-ABL-negative MPNs since it not only provides valuable diagnostic and prognostic information but also identifies potential treatment targets. Since this study describes the importance of screening for known and novel biomarkers, we described in detail three methods that could be easily integrated into a clinical laboratory.

Burkitt's lymphoma-associated c-Myc mutations converge on a dramatically altered target gene response and implicate Nol5a/Nop56 in oncogenesis

Burkitt’s Lymphomas (BLs) acquire consistent point mutations in a conserved domain of Myc, Myc Box I. We report that the enhanced transforming activity of BL-associated Myc mutants can be uncoupled from loss of phosphorylation and increased protein stability. Furthermore, two different BL-associated Myc mutations induced similar gene expression profiles independently of T58 phosphorylation, and these profiles are dramatically different from MycWT. Nol5a/Nop56, which is required for rRNA methylation, was identified as a gene hyperactivated by the BL-associated Myc mutants. We show that Nol5a is necessary for Myc-induced cell transformation, enhances MycWT-induced cell transformation, and increases the size of MycWT induced tumors. Thus, Nol5a expands the link between Myc-induced regulation of nucleolar target genes which are rate-limiting for cell transformation and tumor growth.

Evaluation of cinacalcet HCl treatment after kidney transplantation

BACKGROUND

Hyperparathyroidism often remains or develops after kidney transplantation. Vitamin D sterol used as treatment for an elevated parathyroid hormone (PTH) level and associated bone disease may be contraindicated due to hypercalcemia. The calcimimetic cinacalcet HCl (cinacalcet), which lowers PTH and calcium (Ca) in chronic kidney disease patients, may represent an alternate therapeutic modality.

METHODS

This multicenter, retrospective, observational study examined 41 kidney transplant patients receiving cinacalcet for ≥3 months starting ≥3 months posttransplantation. Levels of intact PTH, Ca, and phosphorus (P) were examined during the assessment phase (3-6 months after initiation).

RESULTS

Median PTH decreased 21.8% during the assessment phase (P < .001), with 32.5% of patients exhibiting a ≥30% decrease in PTH from baseline. Median Ca decreased 6.8% (P < .0001). Median serum P rose 10.0% (P = .0124), but remained within normal limits. The estimated glomerular filtration rate was stable throughout the study.

CONCLUSIONS

Cinacalcet may be useful for the treatment of hyperparathyroidism after kidney transplantation. Randomized, prospectively designed clinical trials are required to confirm these results.

Iatrogenic femoral artery pseudoaneurysms--a review of current methods of diagnosis and treatment

The common femoral artery is commonly used as arterial access for a wide range of radiological and cardiological procedures. Pseudoaneurysm formation is the most common arterial complication of femoral artery catheterization, and is diagnosed using colour Doppler ultrasound. Ultrasound-guided thrombin injection has replaced ultrasound-guided compression as the first-line treatment. The practicalities of thrombin injection (technique and types of thrombin available) and other treatment options are discussed. Awareness of pseudoaneurysm formation and the treatment options allows prompt diagnosis and successful treatment.

Survey for papillomatous digital dermatitis in Australian dairy cattle

OBJECTIVE

To determine whether Treponema-associated papillomatous digital dermatitis (PDD) occurs in Australian dairy cattle.

DESIGN

Mail-out questionnaire and histological and bacteriological examination of biopsy tissue from suspect PDD lesions.

PROCEDURE

The questionnaire was mailed to 375 veterinarians to evaluate their knowledge of PDD, determine if they had observed the disease in Australian dairy cattle, and to request biopsy material from suspicious cases. Biopsies were examined for histological and bacteriological evidence of PDD, including for the presence of spirochaetes.

RESULTS

Eighty-eight replies to the questionnaire were received (23.5%). Of 52 respondents who were aware of PDD as a possible cause of lameness, 26 reported observing the condition in Australian cattle. Of 32 respondents who were unaware of the condition, 6 reported observing lesions that might have been PDD. The majority of reports of PDD-like lesions came from the southern Australian states, the condition occurring during periods of high rainfall and proving responsive to topical or parenteral application of antimicrobials. Biopsies from five erosive lesions showed histological similarity to PDD whereas biopsies from five proliferative lesions were consistent with chronic inflammation, fibroma or cutaneous papilloma. The presence of spirochaetes was not demonstrated in any of the lesions by histological or bacteriological methods.

CONCLUSION

Anecdotal reports and analysis of biopsy material confirm that a condition similar to PDD does occur sporadically in dairy cattle in southern Australia. However, this condition has so far not been shown to be associated with the presence of spirochaetes in the lesions.

Nested deletions of the SRL pathogenicity island of Shigella flexneri 2a

In this study, we determined the boundaries of a 99-kb deletable element of Shigella flexneri 2a strain YSH6000. The element, designated the multiple-antibiotic resistance deletable element (MRDE), had recently been found to contain a 66-kb pathogenicity island (PAI)-like element (designated the SRL PAI) which carries the Shigella resistance locus (SRL), encoding resistance determinants to streptomycin, ampicillin, chloramphenicol, and tetracycline. The YSH6000 MRDE was found to be flanked by two identical IS91 elements present at the S. flexneri homologs of the Escherichia coli genes putA and mdoA on NotI fragment D. Sequence data from two YSH6000-derived MRDE deletants, YSH6000T and S2430, revealed that deletion of the MRDE occurred between the two flanking IS91 elements, resulting in a single IS91 element spanning the two original IS91 loci. Selection for the loss of tetracycline resistance confirmed that the MRDE deletion occurred reproducibly from the same chromosomal site and also showed that the SRL PAI and the SRL itself were capable of independent deletion from the chromosome, thus revealing a unique set of nested deletions. The excision frequency of the SRL PAI was estimated to be 10(-5) per cell in the wild type, and mutation of a P4-like integrase gene (int) at the left end of the SRL PAI revealed that int mediates precise deletion of the PAI.

Ferric dicitrate transport system (Fec) of Shigella flexneri 2a YSH6000 is encoded on a novel pathogenicity island carrying multiple antibiotic resistance genes

Iron uptake systems which are critical for bacterial survival and which may play important roles in bacterial virulence are often carried on mobile elements, such as plasmids and pathogenicity islands (PAIs). In the present study, we identified and characterized a ferric dicitrate uptake system (Fec) in Shigella flexneri serotype 2a that is encoded by a novel PAI termed the Shigella resistance locus (SRL) PAI. The fec genes are transcribed in S. flexneri, and complementation of a fec deletion in Escherichia coli demonstrated that they are functional. However, insertional inactivation of fecI, leading to a loss in fec gene expression, did not impair the growth of the parent strain of S. flexneri in iron-limited culture media, suggesting that S. flexneri carries additional iron uptake systems capable of compensating for the loss of Fec-mediated iron uptake. DNA sequence analysis showed that the fec genes are linked to a cluster of multiple antibiotic resistance determinants, designated the SRL, on the chromosome of S. flexneri 2a. Both the SRL and fec loci are carried on the 66,257-bp SRL PAI, which has integrated into the serX tRNA gene and which carries at least 22 prophage-related open reading frames, including one for a P4-like integrase. This is the first example of a PAI that carries genes encoding antibiotic resistance and the first report of a ferric dicitrate uptake system in Shigella.

A calcimimetic agent lowers plasma parathyroid hormone levels in patients with secondary hyperparathyroidism

BACKGROUND

The calcimimetic agent R-568 lowers plasma parathyroid hormone (PTH) levels in hemodialysis patients with mild secondary hyperparathyroidism, but its efficacy in those with more severe secondary hyperparathyroidism has not been studied.

METHODS

Twenty-one patients undergoing hemodialysis three times per week with plasma PTH levels between 300 and 1200 pg/mL were randomly assigned to 15 days of treatment with either 100 mg of R-568 (N = 16) or placebo (N = 5). Plasma PTH and blood ionized calcium levels were measured at intervals of up to 24 hours after oral doses on days 1, 2, 3, 5, 8, 11, 12, and 15.

RESULTS

Pretreatment PTH levels were 599 +/- 105 (mean +/- SE) and 600 +/- 90 pg/mL in subjects given R-568 or placebo, respectively, and values on the first day of treatment did not change in those given placebo. In contrast, PTH levels fell by 66 +/- 5%, 78 +/- 3%, and 70 +/- 3% at one, two, and four hours, respectively, after initial doses of R-568, remaining below pretreatment values for 24 hours. Blood ionized calcium levels also decreased after the first dose of R-568 but did not change in patients given placebo. Despite lower ionized calcium concentrations on both the second and third days of treatment, predose PTH levels were 422 +/- 70 and 443 +/- 105 pg/mL, respectively, in patients given R-568, and values fell each day by more than 50% two hours after drug administration. Predose PTH levels declined progressively over the first nine days of treatment with R-568 and remained below pretreatment levels for the duration of study. Serum total and blood ionized calcium concentrations decreased from pretreatment levels in patients given R-568, whereas values were unchanged in those given placebo. Blood ionized calcium levels fell below 1.0 mmol/L in 7 of 16 patients receiving R-568; five patients withdrew from study after developing symptoms of hypocalcemia, whereas three completed treatment after the dose of R-568 was reduced.

CONCLUSIONS

The calcimimetic R-568 rapidly and markedly lowers plasma PTH levels in patients with secondary hyperparathyroidism caused by end-stage renal disease.

Milk whey protein concentration and mRNA associated with beta-lactoglobulin phenotype

Two common genetic variants of β-lactoglobulin (β-lg), A and B, exist as co- dominant alleles in dairy cattle (Aschaffenburg, 1968). Numerous studies have shown that cows homozygous for β-lg A have more β-lg and less α-lactalbumin (α-la) and casein in their milk than cows expressing only the B variant of β-lg (Ng-Kwai-Hang et al. 1987; Graml et al. 1989; Hill, 1993; Hill et al. 1995, 1997). These differences have a significant impact on the processing characteristics of the milk. For instance, the moisture-adjusted yield of Cheddar cheese is up to 10% higher using milk from cows of the β-lg BB phenotype compared with milk from cows expressing only the A variant (Hill et al. 1997). All these studies, however, describe compositional differences associated with β-lg phenotype in established lactation only. No information is available on the first few weeks of lactation, when there are marked changes in the concentrations of β-lg and α-la (Pérez et al. 1990).

Mapping access to food in a deprived area: the development of price and availability indices

OBJECTIVE

To develop and map indices to illustrate variation in the cost and availability of healthy food.

DESIGN

Two contiguous wards in London were selected by virtue of their high Carstairs deprivation scores. A 2-km area was defined around a randomly chosen central point. All retail outlets selling food within the area were visited and their location recorded. A list of foods, acceptable to the local ethnically diverse population, which met current dietary guidelines, was devised. Data on the availability and price of 71 food items were collected. Indices were developed using SPSS and mapped using Geographic Information System (GIS) software.

RESULTS

Information on availability and prices were collected from 199 outlets. The mean price index shows how expensive a shop is relative to other shops in the area. The least cost index shows the relative expense of a shop using the cheapest ways of buying their range of foods. Shorthand indices were tested, using data on 19 of the 71 prices. Availability indices are also discussed, including a green availability index and a fresh green availability index. Illustrative maps of the shop locations and the mean price index and fresh green availability index are shown.

CONCLUSIONS

Data can be collected and indices developed which indicate geographic variation in shop 'expensiveness', and in the price and availability of healthy food. GIS software can be used to map these indices, to identify areas with high food prices or low availability.

A randomized phase 3 study of peripheral blood progenitor cell mobilization with stem cell factor and filgrastim in high-risk breast cancer patients

This randomized study compared the number of leukaphereses required to collect an optimal target yield of 5 x 10(6) CD34(+) peripheral blood progenitor cells/kg, using either stem cell factor (SCF) at 20 micrograms/kg/d in combination with Filgrastim at 10 micrograms/kg/d or Filgrastim alone at 10 micrograms/kg/d, from 203 patients with high-risk stage II, III, or IV breast cancer. Leukapheresis began on day 5 of cytokine administration and continued daily until the target yield of CD34(+) cells had been reached or a maximum of 5 leukaphereses performed. By day 5 of leukapheresis, 63% of the patients treated with SCF plus Filgrastim (n = 100) compared with 47% of those receiving Filgrastim alone (n = 103) reached the CD34(+) cell target yield. There was a clinically and statistically significant reduction (P <.05) in the number of leukaphereses required to reach the target yield for the patients receiving SCF plus Filgrastim (median, 4 leukaphereses) compared with patients receiving Filgrastim alone (median, 6 or more leukapherses; ie, <50% of patients reached the target in 5 leukaphereses). All patients receiving SCF were premedicated with antihistamines, albuterol, and pseudoephedrine. Treatment was safe, generally well tolerated, and not associated with life-threatening or fatal toxicity. In conclusion, SCF plus Filgrastim is a more effective peripheral blood progenitor cell (PBPC)-mobilization regimen than Filgrastim alone. In addition to the potential for reduced leukapheresis-related morbidity and costs, SCF offers additional options for obtaining cells for further graft manipulation.

Pressure sore prevention in hospital patients: a clinical audit

Pressure sores cause significant mortality and morbidity as well as being a financial burden on health-care services. Reduction of pressure sore incidence is a Department of Health priority. Pressure sores are accepted as largely preventable complications of illness and disability and the means to achieve prevention are available. The aim of this clinical audit was to identify potential contributing factors to pressure sore acquisition in an acute hospital setting. The results suggest that substantial changes in the approach to clinical management may be needed.

No evidence for basolateral secretion of milk protein in the mammary gland of lactating goats

Recent research suggests that a small percentage of milk proteins may be secreted basolaterally, which would have implications for our work on the permeability of tight junctions in the mammary epithelium. In our work, the presence of alpha-lactalbumin (LA) or lactose in plasma is used as an indicator of permeability. The aim of this study was to examine basolateral secretion by determining the presence of milk proteins in efferent mammary lymph. Five Saanen goats were fitted with mammary lymph catheters and were administered intramammary isosmotic bolus infusions of sucrose control solutions or ethylene glycolbis(beta-aminoethyl ether)-N,N,N',N'-tetraacetic acid to induce leaky tight junctions. Lymph samples were collected before and approximately 5 h after infusion. Lymph was analyzed by Western blotting for the presence of alpha-casein (CN), beta-CN, and alpha-LA No alpha-CN or beta-CN was detected in lymph, but alpha-LA was detected in all lymph samples. Moreover, the signal was much stronger in samples from goats that were treated with ethylene glycol-bis(beta-aminoethyl ether)-N,N,N',N'-tetraacetic acid, and concentrations of alpha-LA in lymph were significantly increased with this treatment. These changes and the absence of casein in lymph suggest increased permeability of tight junctions rather than basolateral secretion. In summary, these data do not support basolateral secretion.

Peripheral blood progenitor cell mobilization using stem cell factor in combination with filgrastim in breast cancer patients

The safety and optimal dose and schedule of stem cell factor (SCF) administered in combination with filgrastim for the mobilization of peripheral blood progenitor cells (PBPCs) was determined in 215 patients with high-risk breast cancer. Patients received either filgrastim alone (10 microg/kg/d for 7 days) or the combination of 10 microg/kg/d filgrastim and 5 to 30 microg/kg/d SCF for either 7, 10, or 13 days. SCF patients were premedicated with antiallergy prophylaxis. Leukapheresis was performed on the final 3 days of cytokine therapy and, after high-dose chemotherapy and infusion of PBPCs, patients received 10 microg/kg/d filgrastim until absolute neutrophil count recovery. The median number of CD34+ cells collected was greater for patients receiving the combination of filgrastim and SCF, at doses greater than 10 microg/kg/d, than for those receiving filgrastim alone (7.7 v 3.2 x 10(6)/kg, P < .05). There were significantly (P < .05) more CD34+ cells harvested for the 20 microg/kg/d SCF (median, 7.9 x 10(6)/kg) and 25 microg/kg/d SCF (median, 13.6 x 10(6)/kg) 7-day combination groups than for the filgrastim alone patients (median, 3.2 x 10(6)/kg). The duration of administration of SCF and filgrastim (7, 10, or 13 days) did not significantly affect CD34+ cell yield. Treatment groups mobilized with filgrastim alone or with the cytokine combination had similar hematopoietic engraftment and overall survival after PBPC infusion. In conclusion, the results of this study indicate that SCF therapy enhances CD34+ cell yield and is associated with manageable levels of toxicity when combined with filgrastim for PBPC mobilization. The combination of 20 microg/kg/d SCF and 10 microg/kg/d filgrastim with daily apheresis beginning on day 5 was selected as the optimal dose and schedule for the mobilization of PBPCs.

Occlusal indices revisited

With the increased interest in measuring the need for orthodontic treatment and the quality of the outcome of orthodontic care, the difficulties in using Grainger's Treatment Priority Index (TPI) to screen children in their tenth year is considered. The first part of the study investigated the level of validity of the TPI using 137 study models and three orthodontists. In the light of the results obtained, the TPI was modified. The clinical judgement of a further two orthodontists was compared with the scores obtained form the modified TPI, using another 121 study models. Three Community Dental Officers were employed initially to assess the training needs for personnel who were not trained in orthodontics. A further five Community Dental Officers were involved in the final training programmes. It was concluded that it will be very difficult to produce an index which considers all aspects of malocclusion and which can be used consistently by personnel untrained in orthodontics.

Amygdaloid influences on brain-stem neurones in the rabbit

1. Electrical stimulation of the central nucleus of the amygdala in the urethane or alpha-chloralose anaesthetized rabbit evokes a bradycardia with a rapid onset and a concomitant fall in arterial blood pressure. 2. Extracellular neuronal activity was recorded in the ipsilateral nucleus tractus solitarius and dorsal vagal nucleus whilst stimulating the ipsilateral central nucleus of the amygdala, the aortic and vagus nerves. 3. A total of 213 neurones were activated by stimulation of at least one of these inputs. 93 of these neurones received a marked excitatory input from the central nucleus with a wide range of latencies (2-100 ms). 50 of these cells also received inputs from either the aortic or vagus nerves, or both. 4. The activity of 42 vagal preganglionic neurones was recorded in the dorsal vagal nucleus of which 22 had properties typical of cardioinhibitory neurones. 9 of these vagal motoneurones received inputs from the central nucleus with latencies between 2 and 100 ms. Of these, 5 had physiological properties indicating they were cardio-inhibitory neurones. 5. We conclude that neurones in the nucleus tractus solitarius and dorsal vagal nucleus can be influenced by descending inputs arising from the central nucleus of the amygdala. Some of these neurones are also likely to be influenced by afferents innervating the thoracic viscera and arterial baroreceptors. The implications of these observations on the role of forebrain-brain-stem interactions in cardiovascular control are discussed.

The effects of a multicomponent smoking cessation program with chronic obstructive pulmonary disease outpatients

While a number of multicomponent treatments have been utilized to control smoking, many of these are not suitable for some populations such as chronic obstructive pulmonary disease (COPD) patients because they consist of aversion procedures which can stress the body's cardiovascular system. Little research has been published regarding nonaversive approaches to smoking control in a COPD patient population. This study examined the long-term effects of a nonaversive multicomponent smoking cessation program consisting of brand fading and stimulus control with a COPD outpatient population as measured by self-report. Using four COPD outpatients, this study employed a multiple baseline design across subjects for a visual analysis of treatment effects. At 3- and 6-month follow-up, one subject had quit smoking. Two subjects who continued to smoke reduced their smoking frequency and drastically reduced their nicotine intake by brand fading to a cigarette containing lower amounts of nicotine. A fourth subject returned to her original brand of cigarettes, although she reduced her smoking frequency. Collaborators and measurements of thiocyanate levels were used as reliability checks on subjects' self-report.

Comparison of dopamine and dobutamine therapy during intraaortic balloon pumping for the treatment of postcardiotomy low-output syndrome

Treatment of postcardiotomy low-output syndrome includes intraaortic balloon pumping (IABP), volume loading, pharmacological afterload reduction, and stimulation with an inotropic agent. This study compares the effectiveness of combined nitroprusside and dopamine therapy and nitroprusside and dobutamine therapy in 12 patients requiring IABP postoperatively. Serial hemodynamic measurements were made before and during infusion of nitroprusside and after administration of the combined therapy (N = 6 in each group). Prior to pharmacological therapy, cardiac index was 1.47 +/- 0.31 L/min/m2 and systemic vascular resistance (SVR) was 3,114 +/- 1,350 dynes sec cm-5 in patients subsequently given dopamine, and 1.59 +/- 0.38 L/min/m2 and 2,661 +/- 405 dynes sec cm-5, respectively, in those given dobutamine. With infusion of nitroprusside, both groups showed significant reduction in SVR. Nitroprusside plus either inotropic agent resulted in augmentation of cardiac index and an additional reduction in SVR, both changes being greater in the group given dopamine. Larger doses of dobutamine than dopamine were needed to achieve similar hemodynamic improvement. We conclude that the addition of an inotropic agent to vasodilator therapy during IABP results in a greater increase in cardiac index and a greater decrease in afterload than a vasodilator alone. In addition to its beneficial effect on renal perfusion at the dose required to effect these improvements, dopamine appears a better inotropic agent than dobutamine for postcardiotomy low-output syndrome.

The feasibility and validity of orthodontic screening of children in their tenth year

The study set out to investigate the problems of the implementation of the Court Report's suggestion that every child in its tenth year be screened for orthodontic treatment by "a dentist with special training in orthodontics' using Grainger's Treatment Priority Index (TPI). The study was divided into two parts. The standardization exercises used 31 orthodontic models of children in their tenth year. The problem of examiner variability, using a Community Dental Officer instead of an orthodontist and of bias that the TPI might have were examined. The main study involved the examination of 362 children in ten separate schools in Oxfordshire and investigated the problem of orthodontic screening at annual school inspections. The findings showed that the TPI may be able to provide a method for screening children in their tenth year if the weights of the clinical entities which are reducing the level of validity of the TPI are identified. The problem of scoring tooth displacements consistently would have to be taken into consideration when training personnel to use the TPI.

Development and evaluation of a long-term, implantable, electrically actuated left ventricular assist system: THI/Gould LVAS

A long-term, implantable, electrically actuated left ventricular assist system (THI/Gould LVAS) is being developed and characterized in vitro and in vivo for utilization in patients with end-stage heart disease. This system consists of five major components: a long-term, implantable blood pump (THI E-type ALVAD); an electrical-mechanical energy converter (Gould Model V); a control unit with batteries; a volume compensation system; and an external power supply and monitoring unit. Two of these components (blood pump and electrical-mechanical energy converter) have been integrated, and are undergoing chronic in vivo evaluations in calves. Thus far, 44 pneumatically and electrically actuated THI/Gould LVAS evaluations have been performed. This experience has resulted in greater than 6.5 years of actuation in vivo, with durations exceeding 1 year. System in vivo performance in terms of durability, mechanical reliability, hemodynamic effectiveness, and biocompatibility has been satisfactory. Demonstration of long-term (2-year) effectiveness in supporting the circulation is the ultimate goal.