Intraclonal heterogeneity is a critical early event in the development of myeloma and precedes the development of clinical symptoms.

The mechanisms involved in the progression from monoclonal gammopathy of undetermined significance (MGUS) and smoldering myeloma (SMM) to malignant multiple myeloma (MM) and plasma cell leukemia (PCL) are poorly understood but believed to involve the sequential acquisition of genetic hits. We performed exome and whole-genome sequencing on a series of MGUS (n=4), high-risk (HR)SMM (n=4), MM (n=26) and PCL (n=2) samples, including four cases who transformed from HR-SMM to MM, to determine the genetic factors that drive progression of disease. The pattern and number of non-synonymous mutations show that the MGUS disease stage is less genetically complex than MM, and HR-SMM is similar to presenting MM. Intraclonal heterogeneity is present at all stages and using cases of HR-SMM, which transformed to MM, we show that intraclonal heterogeneity is a typical feature of the disease. At the HR-SMM stage of disease, the majority of the genetic changes necessary to give rise to MM are already present. These data suggest that clonal progression is the key feature of transformation of HR-SMM to MM and as such the invasive clinically predominant clone typical of MM is already present at the SMM stage and would be amenable to therapeutic intervention at that stage.

Biallelic ATM inactivation significantly reduces survival in patients treated on the United Kingdom Leukemia Research Fund Chronic Lymphocytic Leukemia 4 trial.

PURPOSE: The prognostic significance of ATM mutations in chronic lymphocytic leukemia (CLL) is unclear. We assessed their impact in the context of a prospective randomized trial. PATIENTS AND METHODS: We analyzed the ATM gene in 224 patients treated on the Leukemia Research Fund Chronic Lymphocytic Leukemia 4 (LRF-CLL4) trial with chlorambucil or fludarabine with and without cyclophosphamide. ATM status was analyzed by denaturing high-performance liquid chromatography and was related to treatment response, survival, and the impact of TP53 alterations for the same patient cohort. RESULTS: We identified 36 ATM mutations in 33 tumors, 16 with and 17 without 11q deletion. Mutations were associated with advanced disease stage and involvement of multiple lymphoid sites. Patients with both ATM mutation and 11q deletion showed significantly reduced progression-free survival (median, 7.4 months) compared with those with ATM wild type (28.6 months), 11q deletion alone (17.1 months), or ATM mutation alone (30.8 months), but survival was similar to that in patients with monoallelic (6.7 months) or biallelic (3.4 months) TP53 alterations. This effect was independent of treatment, immunoglobulin heavy chain variable gene (IGHV) status, age, sex, or disease stage. Overall survival for patients with biallelic ATM alterations was also significantly reduced compared with those with ATM wild type or ATM mutation alone (median, 42.2 v 85.5 v 77.6 months, respectively). CONCLUSION: The combination of 11q deletion and ATM mutation in CLL is associated with significantly shorter progression-free and overall survival following first-line treatment with alkylating agents and purine analogs. Assessment of ATM mutation status in patients with 11q deletion may influence the choice of subsequent therapy.

Demonstration of changes in plasma cell subsets in multiple myeloma.

Increases in free light chain (FLC) production are associated with disease progression in multiple myeloma (MM). Using a double immunofluorescence staining method to produce a differential count of plasma cells in bone marrow, single populations were demonstrated, containing intact monoclonal immunoglobulins (M-Igs) in 74% and FLCs only in 8% of cases. However, 18% contained a mixture of both cell populations. Progression from cells making intact M-Ig to cells restricted to FLC only production occurred in individual cases during the course of their disease. The presence of FLC only cells was associated with shortened survival.

Insights into the multistep transformation of MGUS to myeloma using microarray expression analysis.

To define specific pathways important in the multistep transformation process of normal plasma cells (PCs) to monoclonal gammopathy of uncertain significance (MGUS) and multiple myeloma (MM), we have applied microarray analysis to PCs from 5 healthy donors (N), 7 patients with MGUS, and 24 patients with newly diagnosed MM. Unsupervised hierarchical clustering using 125 genes with a large variation across all samples defined 2 groups: N and MGUS/MM. Supervised analysis identified 263 genes differentially expressed between N and MGUS and 380 genes differentially expressed between N and MM, 197 of which were also differentially regulated between N and MGUS. Only 74 genes were differentially expressed between MGUS and MM samples, indicating that the differences between MGUS and MM are smaller than those between N and MM or N and MGUS. Differentially expressed genes included oncogenes/tumor-suppressor genes (LAF4, RB1, and disabled homolog 2), cell-signaling genes (RAS family members, B-cell signaling and NF-kappaB genes), DNA-binding and transcription-factor genes (XBP1, zinc finger proteins, forkhead box, and ring finger proteins), and developmental genes (WNT and SHH pathways). Understanding the molecular pathogenesis of MM by gene expression profiling has demonstrated sequential genetic changes from N to malignant PCs and highlighted important pathways involved in the transformation of MGUS to MM.

Virtual Clinical Trials in PET Imaging for Improved Diagnosis of and Evaluation of Therapies for Cancer

Thesis (Ph.D.)--University of Washington, 2016-08

Epidemias bacterianas emergentes do século XXI

As doenças infeciosas distantes de serem um problema do passado têm aumentado drasticamente nestes últimos anos, causando epidemias emergentes, quer de origem bacteriana ou vírica ou de outros tipos de microrganismos. Esta dissertação tem como objetivo uma pesquisa atual bibliográfica sobre o estudo de algumas epidemias bacterianas emergentes do século XXI, como a Tuberculose, Cólera, Staphylococcus aureus resistente à meticilina (MRSA) e Meningite Meningocócica, bem como os seus dados epidemiológicos. A Tuberculose é uma das doenças mais antigas, que apresenta uma elevada taxa de mortalidade e com o passar do tempo tem vindo a aumentar a nível mundial. A TB é causada por uma bactéria denominada Mycobacterium tuberculosis que normalmente afeta os pulmões e outros órgãos. O tratamento, a prevenção e o diagnóstico precoce são pontos essenciais, para ter um bom desfecho para o doente. A Cólera tem-se propagado pelo mundo desde o século XX. Esta doença caracteriza-se por uma diarreia aguda grave que é causada pela bactéria Vibrio cholerae. O seu tratamento se for realizado precocemente é tratado facilmente, com apenas hidratação com sais orais. A prevenção é uma medida essencial para ter um bom prognóstico, e evitar surtos emergentes desta infeção. Devido à sua virulência, Staphylococcus aureus é responsável por infeções graves adquiridas em hospital e na comunidade. Na maioria das vezes esta infeção é assintomática, mas pode causar infeções graves até mesmo fatais. Devido às resistências aos antibióticos β-lactâmicos e de outros tipos de antibióticos, e também devido ao aumento do número crescente de quadros infeciosos de MRSA, houve necessidade de novos antibióticos como o linezolide, as cefasloporinas de 5ª geração no combate a estas infeções. As medidas de prevenção são essenciais, visto que se não forem realizadas pode haver progressão da doença. Além de um estudo científico constante dos mecanismos de resistências desta bactéria, ser essencial. A meningite bacteriana é um grave problema de Saúde Pública devido à alta incidência em crianças. A meningite meningocócica é causada pela bactéria Neisseria meningitidis que origina um processo inflamatório das meninges. Há algum tempo atrás a mortalidade era elevada, mas com o advento da antibioterapia reduziu significativamente. As vacinas fizeram com que ocorresse uma mudança bastante significativa na epidemiologia desta patologia, e mais uma vez a prevenção é essencial.

Multiple endocrine neoplasia, the old and the new: a mini review

Multiple endocrine neoplasia syndromes have since been classified as types 1 and 2, each with specific phenotypic patterns. MEN1 is usually associated with pituitary, parathyroid and paraneoplastic neuroendocrine tumours. The hallmark of MEN2 is a very high lifetime risk of developing medullary thyroid carcinoma (MTC) more than 95% in untreated patients. Three clinical subtypesdMEN2A, MEN2B, and familial MTC (FMTC) have been defined based on the risk of pheochromocytoma, hyperparathyroidism, and the presence or absence of characteristic physical features). MEN2 occurs as a result of germline activating missense mutations of the RET (REarranged during Transfection) proto-oncogene. MEN2-associated mutations are almost always located in exons 10, 11, or 13 through 16. Strong genotype-phenotype correlations exist with respect to clinical subtype, age at onset, and aggressiveness of MTC in MEN2. These are used to determine the age at which prophylactic thyroidectomy should occur and whether screening for pheochromocytoma or hyperparathyroidism is necessary. Specific RET mutations can also impact management in patients presenting with apparently sporadic MTC. Therefore, genetic testing should be performed before surgical intervention in all patients diagnosed with MTC. Recently, Pellegata et al. have reported that germline mutations in CDKN1B can predispose to the development of multiple endocrine tumours in both rats and humans and this new MEN syndrome is named MENX and MEN4, respectively. CDKN1B. A recent report showed that in sporadic MTC, CDKN1B V109G polymorphism correlates with a more favorable disease progression than the wild-type allele and might be considered a new promising prognostic marker. New insights on MEN syndrome pathogenesis and related inherited endocrine disorders are of particular interest for an adequate surgical and therapeutic approach.

The role of intracellular calcium perturbations in muscle damage and dysfunction in mouse models of muscular dystrophy

Duchenne muscular dystrophy (DMD) is a neuromuscular disease caused by mutations in the dystrophin gene. DMD is clinically characterized by severe, progressive and irreversible loss of muscle function, in which most patients lose the ability to walk by their early teens and die by their early 20’s. Impaired intracellular calcium (Ca2+) regulation and activation of cell degradation pathways have been proposed as key contributors to DMD disease progression. This dissertation research consists of three studies investigating the role of intracellular Ca2+ in skeletal muscle dysfunction in different mouse models of DMD. Study one evaluated the role of Ca2+-activated enzymes (proteases) that activate protein degradation in excitation-contraction (E-C) coupling failure following repeated contractions in mdx and dystrophin-utrophin null (mdx/utr-/-) mice. Single muscle fibers from mdx/utr-/- mice had greater E-C coupling failure following repeated contractions compared to fibers from mdx mice. Moreover, protease inhibition during these contractions was sufficient to attenuate E-C coupling failure in muscle fibers from both mdx and mdx/utr-/- mice. Study two evaluated the effects of overexpressing the Ca2+ buffering protein sarcoplasmic/endoplasmic reticulum Ca2+-ATPase 1 (SERCA1) in skeletal muscles from mdx and mdx/utr-/- mice. Overall, SERCA1 overexpression decreased muscle damage and protected the muscle from contraction-induced injury in mdx and mdx/utr-/- mice. In study three, the cellular mechanisms underlying the beneficial effects of SERCA1 overexpression in mdx and mdx/utr-/- mice were investigated. SERCA1 overexpression attenuated calpain activation in mdx muscle only, while partially attenuating the degradation of the calpain target desmin in mdx/utr-/- mice. Additionally, SERCA1 overexpression decreased the SERCA-inhibitory protein sarcolipin in mdx muscle but did not alter levels of Ca2+ regulatory proteins (parvalbumin and calsequestrin) in either dystrophic model. Lastly, SERCA1 overexpression blunted the increase in endoplasmic reticulum stress markers Grp78/BiP in mdx mice and C/EBP homologous protein (CHOP) in mdx and mdx/utr-/- mice. Overall, findings from the studies presented in this dissertation provide new insight into the role of Ca2+ in muscle dysfunction and damage in different dystrophic mouse models. Further, these findings support the overall strategy for improving intracellular Ca2+ control for the development of novel therapies for DMD.

An investigation into the role of interleukin-6 in linking systemic and local inflammatory responses in patients with colorectal cancer

Colorectal cancer is the second most common cause of cancer death in the UK. It is accepted that both tumour and host factors are important determinants of disease progression and survival. While systemic and local inflammatory responses are increasingly recognized to be of particular importance the understanding of the mechanisms linking these important inflammatory processes remains unclear. This thesis examines the prognostic importance of measures of systemic and local inflammation and proposes a hypothesis for a link between tumour necrosis, systemic and local inflammatory responses in patients with colorectal cancer. Chapter 3 reports the comparison of the prognostic value of longitudinal measurements of systemic inflammation in patients undergoing curative resection of colorectal cancer. In Chapter 3 the results demonstrate that there was no significant overall change in either mGPS or NLR from pre- to post- operatively. This study highlighted the associations between pre- and post- operative mGPS and NLR and T-stage (p<0.001), TNM stage (p<0.005) and cancer-specific survival. The relationships between pre-operative measurements were examined using multivariate analysis. For pre-operative measurement both mGPS and NLR were associated with cancer-specific survival while when post-operative measures were examined only mGPS was specifically associated with cancer-specific survival (HR 4.81, CI 2.13-10.83, P<0.001). Chapter 4 examines the prognostic value of the Klintrup-Makinen scoring method and the existing limitations with regard to its clinical utility. An automated scoring method using commercially available image analysis software was developed and compared with manual scoring of tumour inflammatory infiltrates. This study demonstrated that both manual K-M scoring (p<0.001) and automated K-M scoring (p<0.05) had prognostic value in patients who had undergone potentially curative resection of colorectal cancer, and that the novel automated method may provide an objective method of assessment of tumour inflammatory infiltrates using routinely stained haematoxylin and eosin sections of tumour samples. In chapter 5 a hypothesis was proposed that Interleukin-6 may link tumour necrosis and systemic and local inflammatory responses in patients with colorectal cancer. This chapter examined the basis for this hypothesis, which is presented in figure 5.1. In addition, in chapter 5 the importance of this potential link is examined. In chapter 6, the hypothesis outlined in chapter 5 was examined in a cohort of patients who had undergone attempted curative resection of colorectal cancer. This study examined the inter-relationships between circulating mediators, in particular IL-6, tumour necrosis and systemic and local inflammatory responses. This results of this study demonstrated that IL-6 was associated with tumour necrosis (<0.001) and mGPS (<0.001) independent of T-stage. Thus adding weight to the hypothesis that elevated circulating concentrations of IL-6 may play a role in modulating both the systemic and local inflammatory responses in patients with cancer. Chapter 7 further develops the hypothesis that IL-6 signalling may be important in modulating systemic and local inflammatory responses in patients with colorectal cancer. Further, in chapter 7 the basis for the role of trans-signalling in this signaling pathway was examined. In this study, we reported that neither expression of the soluble IL-6 receptor or soluble gp130 were associated with systemic or local inflammatory responses. As a result the possible reasons for these findings were explored and future work suggested. A prospective database of patients undergoing attempted curative resection of colorectal cancer in Glasgow Royal Infirmary was used throughout this thesis. This database was created and is maintained regularly by successive research fellows at the Royal Infirmary. The work presented in this thesis highlights the importance of the host response in the form of systemic and local inflammation in patients with colorectal cancer and proposes a link between these responses and tumour necrosis. In addition, this work adds weight to the body of evidence suggesting that assessment of these host responses may improve stratification to treatment for patients with colorectal cancer. Further, this work proposes a mechanistic link, between tumour necrosis, systemic and local inflammatory responses through Interleukin-6, that merits further investigation.

Effectiveness of Psycho-Educational Intervention in HIV Patients' Treatment

Adherence to Highly Active Antiretroviral Therapy (HAART) is the main prognostic factor associated with HIV disease progression and death. The aim was to evaluate the effectiveness of a psycho-educational program to promote adherence to HAART in HIV patients. A longitudinal study (n = 102) over 9 months in an Infectious Diseases Hospital was carried out. Adherence to HAART was measured with standardized scales and values of viral load. Two groups were defined: adherents and non-adherents. In the latter, a psycho-educational program was implemented and 6 months later measured adherence to HAART. Knowledge about the infection, CD4 T lymphocytes and HIV-ribonucleic acid values were measured before and after this program. The sample was predominantly male (70%), heterosexual (78%), with a mean age of 49 (SD = 12.7) years, and 48% of participants were not adhering to HAART. After the program, non-adherence decreased to 21.6%. Knowledge about the infection increased from 79 to 97%. A significant increase in CD4 T lymphocytes (mean 540-580) and a decrease in viral load (mean 5411-3052) were observed, the latter of statistical significance. This program seems to be feasible and efficient, improving adherence to HAART.

Vandetanib for the Treatment of Advanced Medullary Thyroid Cancer Outside a Clinical Trial: Results from a French Cohort

International audience

Análise de expressão de genes da família SETD em leucemia linfocítica crônica

Dissertação (mestrado)—Universidade de Brasília, Faculdade de Ciências da Saúde, Programa de Pós-Graduação em Ciências da Saúde, 2015.

Pflegerische Versorgungskonzepte für Personen mit Demenzerkrankungen

Einleitung: In Deutschland leiden derzeit etwa eine Million Menschen an einer Demenzerkrankung. Aufgrund der demografischen Entwicklung ist mit einem deutlichen Anstieg der Häufigkeit solcher Erkrankungen in den kommenden Jahren zu rechnen. Demenz ist in höherem Alter die häufigste Ursache von Pflegebedürftigkeit. Da diese Krankheiten in der Regel nicht heilbar sind, liegt der Fokus der Pflege auf der Verzögerung des Voranschreitens der Erkrankung sowie der Aufrechterhaltung von Funktionsfähigkeit und Lebensqualität der Betroffenen. Fragestellung: Wie ist die Evidenz für pflegerische Konzepte für Patienten mit Demenz hinsichtlich gebräuchlicher Endpunkte wie kognitive Funktionsfähigkeit, Fähigkeit zur Durchführung von Aktivitäten des täglichen Lebens, Lebensqualität, Sozialverhalten? Wie ist die Kosten-Effektivität der betrachteten Pflegekonzepte zu bewerten? Welche ethischen, sozialen oder juristischen Aspekte werden in diesem Kontext diskutiert? Methoden: Auf Basis einer systematischen Literaturrecherche werden randomisierte kontrollierte Studien (RCT) mit mindestens 30 Teilnehmern zu folgenden Pflegekonzepten eingeschlossen: Validation/emotionsorientierte Pflege, Ergotherapie, sensorische Stimulation, Entspannungsverfahren, Realitätsorientierung und Reminiszenz. Die Studien müssen ab 1997 (für den ökonomischen Teil ab 1990) in deutscher oder englischer Sprache publiziert worden sein. Ergebnisse: Insgesamt 20 Studien erfüllen die Einschlusskriterien. Davon befassen sich drei Studien mit der Validation/emotionsorientierte Pflege, fünf Studien mit der Ergotherapie, sieben Studien mit verschiedenen Varianten sensorischer Stimulation, je zwei Studien mit der Realitätsorientierung und der Reminiszenz und eine Studie mit einem Entspannungsverfahren. Keine signifikanten Unterschiede zwischen Interventions- und Kontrollgruppe berichten zwei von drei Studien zur Validation/emotionsorientierten Pflege, zwei von fünf Studien zur Ergotherapie, drei von sieben Studien zur sensorischen Stimulation, beide Studien zur Reminiszenz, und die Studie zur Entspannung. Von den verbleibenden zehn Studien berichten sieben teilweise positive Ergebnisse zugunsten der Intervention und drei Studien (Ergotherapie, Aromatherapie, Musik/Massage) berichten positive Effekte der Intervention hinsichtlich aller erhobenen Zielkriterien. Sechs Publikationen berichten ökonomische Ergebnisse von Pflegemaßnahmen. Eine Studie berichtet Zusatzkosten von 16 GBP (24,03 Euro (2006)) pro Patient pro Woche für Beschäftigungstherapie. Zwei weitere Veröffentlichungen geben inkrementelle Kosten von 24,30 USD (25,62 Euro (2006)) pro gewonnenen Mini-mental-state-examination-(MMSE)-Punkt pro Monat bzw. 1.380.000 ITL (506,21 Euro (2006)) pro gewonnenen MMSE-Punkt an. Zwei Publikationen berichten über Mischinterventionen, wobei einmal die Zusatzkosten für ein Aktivitätsprogramm (1,13 USD (1,39 Euro (2006)) pro Tag pro Pflegebedürftigem) und einmal der zeitliche Mehraufwand für die Betreuung mobiler Demenzpatienten (durchschnittlich 45 Minuten zusätzliche Pflegezeit pro Tag) berichtet wird. Hinsichtlich ethisch-sozialer Aspekte wird vor allem die Selbstbestimmung von Demenzpatienten diskutiert. Aus einer Demenzdiagnose lässt sich danach nicht zwingend schließen, dass die Betroffenen nicht eigenständig über eine Studienteilnahme entscheiden können. Im juristischen Bereich versucht die Regierung mit dem Pflege-Weiterentwicklungsgesetz (PfWG) die finanzielle Lage und die Betreuung der Pflegenden und Gepflegten zu verbessern. Weitere Fragestellungen rechtlicher Natur betreffen die Geschäftsfähigkeit bzw. die rechtliche Vertretung sowie die Deliktfähigkeit von an Demenz erkrankten Personen. Diskussion: Es gibt nur wenige methodisch angemessene Studien zu den in diesem Bericht berücksichtigten pflegerischen Konzepten für Demenzkranke. Die Studien haben überwiegend kleine Fallzahlen, und weisen erhebliche methodische Unterschiede hinsichtlich der Einschlusskriterien, der Durchführung, und der erfassten Zielkriterien auf. Diese Heterogenität zeigt sich auch in den Ergebnissen: in der Hälfte der eingeschlossen Studien gibt es keine positiven Effekte der Intervention im Vergleich zur Kontrollgruppe. Die andere Hälfte der Studien berichtet zum Teil positive Effekte bezüglicher unterschiedlicher Zielkriterien. Die ökonomischen Studien sind methodisch und thematisch nicht dazu geeignet die aufgeworfenen Fragestellungen zu beantworten. Ethische, soziale und juristische Aspekte werden diskutiert, aber nicht systematisch im Rahmen von Studien erfasst. Schlussfolgerung: Basierend auf der derzeitigen Studienlage liegt für keines der untersuchten Pflegekonzepte ausreichende Evidenz vor. Fehlende Evdienz bedeutet in diesem Kontext jedoch nicht zwingend fehlende Wirksamkeit. Vielmehr sind weitere Studien zu diesem Thema notwendig. Wünschenswert wären insbesondere Studien, die in Deutschland unter den Rahmenbedingungen des hiesigen Ausbildungs- und Pflegesystems durchgeführt werden. Dies gilt auch für die gesundheitsökonomische Bewertung der Pflege

Animal Models of Friedreich Ataxia

Friedreich ataxia (FRDA) is the most common form of autosomal-recessive ataxia. Common nonmotor features include cardiomyopathy and diabetes mellitus. At present, no effective treatments are available to prevent disease progression. Age of onset varies from infancy to adulthood. In the majority of patients, FRDA is caused by intronic GAA expansions in FXN, which encodes a highly-conserved small mitochondrial matrix protein, frataxin. A mouse model of FRDA has been difficult to generate because complete loss of frataxin causes early embryonic lethality. Although there are some controversies about the function of frataxin, recent biochemical and structural studies have confirmed that it is a component of the multiprotein complex that assembles iron-sulfur clusters in the mitochondrial matrix. The main consequences of frataxin deficiency are energy deficit, altered iron metabolism, and oxidative damage.

Co-administration of plasmid-encoded granulocyte-macrophage colony-stimulating factor increases human immunodeficiency virus-1 DNA vaccine-induced polyfunctional CD4+ T-cell responses

T-cell based vaccines against human immunodeficiency virus (HIV) generate specific responses that may limit both transmission and disease progression by controlling viral load. Broad, polyfunctional, and cytotoxic CD4+ T-cell responses have been associated with control of simian immunodeficiency virus/HIV-1 replication, supporting the inclusion of CD4+ T-cell epitopes in vaccine formulations. Plasmid-encoded granulocyte-macrophage colony-stimulating factor (pGM-CSF) co-administration has been shown to induce potent CD4+ T-cell responses and to promote accelerated priming and increased migration of antigen-specific CD4+ T-cells. However, no study has shown whether co-immunisation with pGM-CSF enhances the number of vaccine-induced polyfunctional CD4+ T-cells. Our group has previously developed a DNA vaccine encoding conserved, multiple human leukocyte antigen (HLA)-DR binding HIV-1 subtype B peptides, which elicited broad, polyfunctional and long-lived CD4+ T-cell responses. Here, we show that pGM-CSF co-immunisation improved both magnitude and quality of vaccine-induced T-cell responses, particularly by increasing proliferating CD4+ T-cells that produce simultaneously interferon-γ, tumour necrosis factor-α and interleukin-2. Thus, we believe that the use of pGM-CSF may be helpful for vaccine strategies focused on the activation of anti-HIV CD4+ T-cell immunity.