Pathologic features of response to neoadjuvant anti-PD-1 in resected non-small-cell lung carcinoma: a proposal for quantitative immune-related pathologic response criteria (irPRC).

Background: Neoadjuvant anti-PD-1 may improve outcomes for patients with resectable NSCLC and provides a critical window for examining pathologic features associated with response. Resections showing major pathologic response to neoadjuvant therapy, defined as ≤10% residual viable tumor (RVT), may predict improved long-term patient outcome. However, %RVT calculations were developed in the context of chemotherapy (%cRVT). An immune-related %RVT (%irRVT) has yet to be developed. Patients and methods: The first trial of neoadjuvant anti-PD-1 (nivolumab, NCT02259621) was just reported. We analyzed hematoxylin and eosin-stained slides from the post-treatment resection specimens of the 20 patients with non-small-cell lung carcinoma who underwent definitive surgery. Pretreatment tumor biopsies and preresection radiographic 'tumor' measurements were also assessed. Results: We found that the regression bed (the area of immune-mediated tumor clearance) accounts for the previously noted discrepancy between CT imaging and pathologic assessment of residual tumor. The regression bed is characterized by (i) immune activation-dense tumor infiltrating lymphocytes with macrophages and tertiary lymphoid structures; (ii) massive tumor cell death-cholesterol clefts; and (iii) tissue repair-neovascularization and proliferative fibrosis (each feature enriched in major pathologic responders versus nonresponders, P < 0.05). This distinct constellation of histologic findings was not identified in any pretreatment specimens. Histopathologic features of the regression bed were used to develop 'Immune-Related Pathologic Response Criteria' (irPRC), and these criteria were shown to be reproducible amongst pathologists. Specifically, %irRVT had improved interobserver consistency compared with %cRVT [median per-case %RVT variability 5% (0%-29%) versus 10% (0%-58%), P = 0.007] and a twofold decrease in median standard deviation across pathologists within a sample (4.6 versus 2.2, P = 0.002). Conclusions: irPRC may be used to standardize pathologic assessment of immunotherapeutic efficacy. Long-term follow-up is needed to determine irPRC reliability as a surrogate for recurrence-free and overall survival.

DOCK2 interacts with FLT3 and modulates the survival of FLT3-expressing leukemia cells.

The FMS-like tyrosine kinase-3 (FLT3) gene is the most commonly mutated gene in acute myeloid leukemia (AML), and patients carrying internal tandem duplication (ITD) mutations have a poor prognosis. Long-term inhibition of FLT3 activity in these patients has been elusive. To provide a more complete understanding of FLT3 biology, a mass spectroscopy-based screen was performed to search for FLT3-interacting proteins. The screen identified dedicator of cytokinesis 2 (DOCK2), which is a guanine nucleotide exchange factor for Rho GTPases, and its expression is limited to hematolymphoid cells. We show that DOCK2 is expressed in leukemia cell lines and primary AML samples, and DOCK2 co-immunoprecipitates with wild-type FLT3 and FLT3/ITD. Knockdown (KD) of DOCK2 by shRNA selectively reduced cell proliferation and colony formation in leukemia cell lines with increased FLT3 activity, and greatly sensitized these cells to cytarabine treatment, alone and in combination with FLT3 tyrosine kinase inhibitors. DOCK2 KD in an FLT3/ITD-positive leukemia cell line also significantly prolonged survival in a mouse xenograft model. These findings suggest that DOCK2 is a potential therapeutic target for novel AML treatments, as this protein regulates the survival of leukemia cells with elevated FLT3 activity and sensitizes FLT3/ITD leukemic cells to conventional antileukemic agents.

Low alanine aminotransferase levels and higher number of cardiovascular events in people with Type 2 diabetes: analysis of the Fenofibrate Intervention and Event Lowering in Diabetes (FIELD) study.

AIMS: To determine whether alanine aminotransferase or gamma-glutamyltransferase levels, as markers of liver health and non-alcoholic fatty liver disease, might predict cardiovascular events in people with Type 2 diabetes. METHODS: Data from the Fenofibrate Intervention and Event Lowering in Diabetes study were analysed to examine the relationship between liver enzymes and incident cardiovascular events (non-fatal myocardial infarction, stroke, coronary and other cardiovascular death, coronary or carotid revascularization) over 5 years. RESULTS: Alanine aminotransferase measure had a linear inverse relationship with the first cardiovascular event occurring in participants during the study period. After adjustment, for every 1 sd higher baseline alanine aminotransferase measure (13.2 U/l), the risk of a cardiovascular event was 7% lower (95% CI 4-13; P = 0.02). Participants with alanine aminotransferase levels below and above the reference range 8-41 U/l for women and 9-59 U/l for men, had hazard ratios for a cardiovascular event of 1.86 (95% CI 1.12-3.09) and 0.65 (95% CI 0.49-0.87), respectively (P = 0.001). No relationship was found for gamma-glutamyltransferase. CONCLUSIONS: The data may indicate that in people with Type 2 diabetes, which is associated with higher alanine aminotransferase levels because of prevalent non-alcoholic fatty liver disease, a low alanine aminotransferase level is a marker of hepatic or systemic frailty rather than health.

Anthropometric assessment of nutritional status in adolescent populations in humanitarian emergencies.

OBJECTIVE: To outline the difficulties and suggest potential solutions in anthropometric assessment of adolescents during humanitarian emergencies. DESIGN: Literature review. SETTING: Multiple settings in which the nutritional status of adolescents has been assessed using anthropometric measurements. SUBJECTS: Adolescents in multiple populations. INTERVENTIONS: None. RESULTS: The use of anthropometry may be more difficult in adolescents than in other age groups because anthropometric indices in normally nourished adolescents change with age and sexual development. Moreover, survey and reference populations may differ in the age at which certain pubertal landmarks are attained, requiring adjustment for differences between survey and reference populations. Adolescent populations may also differ by ethnicity in various body proportions that affect anthropometric indices. Adjustment may be required when the body proportions of adolescents in the reference population differ from those in the population assessed. CONCLUSIONS: Although no definitive recommendation can be made regarding which anthropometric indices are the most appropriate for adolescents, some revisions may improve current practices. Weight-for-height could be used for prepubertal adolescents and body mass index could be used for postpubertal adolescents. Because cut-off points are age-specific, age should be collected as accurately as possible for all adolescents measured during screening or survey activities. The WHO-recommended reference population of US adolescents is inappropriate in most populations of adolescents. Adolescents should never undergo nutritional assessment in isolation; other population subgroups should be included, and other health, nutrition and food data should be collected at the same time. SPONSORSHIP: The United Nations Administrative Committee on Coordination/Sub-Committee on Nutrition.

Localization of a susceptibility gene for familial nonmedullary thyroid carcinoma to chromosome 2q21.

The familial form of nonmedullary thyroid carcinoma (NMTC) is a complex genetic disorder characterized by multifocal neoplasia and a higher degree of aggressiveness than its sporadic counterpart. In a large Tasmanian pedigree (Tas1) with recurrence of papillary thyroid carcinoma (PTC), the most common form of NMTC, an extensive genomewide scan revealed a common haplotype on chromosome 2q21 in seven of the eight patients with PTC. To verify the significance of the 2q21 locus, we performed linkage analysis in an independent sample set of 80 pedigrees, yielding a multipoint heterogeneity LOD score (HLOD) of 3.07 (alpha=0.42), nonparametric linkage (NPL) 3.19, (P=.001) at marker D2S2271. Stratification based on the presence of at least one case of the follicular variant of PTC, the phenotype observed in the Tas1 family, identified 17 such pedigrees, yielding a maximal HLOD score of 4.17 (alpha=0.80) and NPL=4.99 (P=.00002) at markers AFMa272zg9 and D2S2271, respectively. These results indicate the existence of a susceptibility locus for familial NMTC on chromosome 2q21.

Urinary selenium and iodine during pregnancy and lactation.

The New Zealand environment is low in selenium and iodine, and is therefore ideally suited for the study of these anionic trace elements. The aim of this study was to determine urinary excretion of selenium and iodine during pregnancy and postpartum as part of an investigation of the influence of pregnancy and lactation on selenium metabolism in women of low selenium status. In a double-blind placebo-controlled study, 35 women in the earliest stages of pregnancy and 17 non-pregnant women were recruited in Dunedin, New Zealand. Eighteen pregnant women received 50 microg selenium as L-selenomethionine, while the others received a placebo daily during pregnancy and 12 months postpartum. The non-pregnant women received the supplement, serving as a positive control. Blood samples and twenty-four hour urine samples were collected monthly during pregnancy and at 3, 6, and 12 months postpartum for analysis of selenium and iodine. Selenium content in plasma and urinary excretion of selenium fell during pregnancy; however, total excretion of selenium was greater during pregnancy than postpartum. Urinary iodine excretion was much lower than reported previously in New Zealand. Due to large intra- and inter-subject variability, no trends in iodide excretion were observed. Factors which influence urinary excretion of selenium include dietary intake, but more closely, plasma concentrations of selenium (which is probably related to total selenium pool), creatinine excretion and therefore lean body mass, and glomerular filtration rate. The exact mechanism and sequence of events remains unclear and future studies incorporating new speciation techniques are necessary.

An estimation of selenium requirements for New Zealanders.

BACKGROUND: Current US dietary recommendations for selenium are based on maximization of plasma glutathione peroxidase (GSHPx) activity according to data from one study of Chinese men. OBJECTIVE: The effect of various amounts of supplemental selenium on GSHPx activities in blood of New Zealand adults was investigated to calculate a selenium requirement for New Zealanders. The effect on plasma selenoprotein P and thyroid hormones was also investigated. DESIGN: Fifty-two adults with low blood selenium concentrations ingested a placebo or 10, 20, 30, or 40 microgram Se as L-selenomethionine daily for 20 wk. RESULTS: Plasma and whole-blood GSHPx activities increased in all supplemented groups but reached a plateau only in the group receiving 40 microgram Se, as determined by statistical analysis. Increases in selenoprotein P were greater than those for selenium and GSHPx at all supplement intakes. Thyroxine concentrations decreased in supplemented groups but the decrease was significantly different from that in the control group only for the 10-microgram group and for all supplemented groups combined. CONCLUSIONS: An upper estimated requirement of 90 microgram Se/d was calculated as the intake necessary for maximization of plasma GSHPx activity, as used in the derivation of the US recommended daily allowance. Our lower estimated requirement of 39 microgram Se/d was the intake necessary to reach two-thirds of maximal GSHPx activity, as was used in calculating the World Health Organization normative requirement. The lower estimate is a realistic goal for New Zealand but the upper estimate could be achieved only with regular inclusion of high-selenium foods.

At least three genes account for familial papillary thyroid carcinoma: TCO and MNG1 excluded as susceptibility loci from a large Tasmanian family.

Recent studies have mapped two susceptibility loci which appear to account for familial multinodular goitre (MNG1) and a variant of familial papillary thyroid cancer (PTC), with associated multinodular goitre (TCO). A Tasmanian family (Tas1) has been identified with an autosomal dominant form of PTC. This study has examined the MNG1 and TCO loci to determine if they are similarly predisposing the Tas1 family to PTC. Linkage analysis using identical microsatellite markers described in the two previous studies was used to determine the significance of these loci in the Tasmanian family. The resultant LOD scores were sufficiently negative using multipoint parametric analysis to exclude these two loci from involvement in the Tasmanian family. In addition, six candidate genes, RET, TRK, MET, TSHR, APC and PTEN were also excluded as susceptibility genes in Tas1 by using microsatellites that are positioned in or in close proximity to these genes. These results suggest that there are at least three susceptibility genes that predispose families to familial PTC.

A comparison of methods of assessment of dietary selenium intakes in Otago, New Zealand.

The aims of the present study were (1) to compare three methods of assessment of dietary Se intake, i.e. chemical analysis of duplicate diets, diet records and a food-frequency questionnaire (FFQ) designed specifically for Se, and (2) to determine dietary Se intakes of residents of Otago, New Zealand. The FFQ was completed by 110 free-living adults. Diet records (3 d) and duplicate diet collections were carried out by forty-three of these subjects chosen on the basis of low blood Se concentration, and during a period when consumption of the high-Se foods fish, kidney, liver and Brazil nuts was discouraged. Mean Se intakes were similar for duplicate diet analysis (29 (SD 13) micrograms/d) and diet record assessments (28 (SD 15) micrograms/d). Estimates of intakes from the FFQ for the subgroup of forty-three subjects were higher (51 (SD 26) micrograms/d) than those from duplicate diets and diet records. Values from duplicate diet analysis and diet record assessments were strongly correlated (r 0.7, P = 0.0001), but difference plots indicated a lack of agreement between the two methods. Thus, diet record assessment was not adequate for predicting dietary Se intakes of individuals. Significant correlations were found for relationships between Se intake from duplicate diets (microgram/kg body weight per d) and plasma Se, Se intake from diet records (microgram/d and microgram/kg body weight per d) and plasma Se; and Se intake from the FFQ and whole-blood Se. Se intakes from duplicate diets and diet records were similar to those reported previously for New Zealanders, but lower than the recommended intakes in the USA (National Research Council, 1989), Australia (Truswell et al. 1990) and the UK (Department of Health, 1991) and the World Health Organization/Food and Agriculture Organization/International Atomic Energy Agency (1996) normative requirement.

Selenium supplementation affects the retention of stable isotopes of selenium in human subjects consuming diets low in selenium.

Twenty-nine women and fifteen men from an area of low Se intake (South Island of New Zealand) consumed 100 micrograms stable 74Se, as selenate given in water after an overnight fast, and blood was collected for 3 weeks. They were then divided into five groups and supplemented with 0, 10, 20, 30 and 40 micrograms Se/d (as selenomethionine) for 5 months. After 5 months, they received a second dose of 74Se identical to the first. Supplementation significantly altered retention of 74Se in the plasma, but not in the erythrocytes or platelets. Subjects receiving the placebo retained the greatest amount, and subjects receiving 30 micrograms supplemental Se/d retained the least 74Se. Supplementation resulted in relatively more isotope being retained in a medium molecular mass protein considered to be albumin, and relatively less in another fraction considered to be selenoprotein P. The lack of many observed changes in retention of stable Se, and the shift in retention among the plasma proteins, suggests that supplemental Se was not being used to replete critical pools of Se, probably because of adaptation to low Se intake.

Parathyroid-hormone-related protein in sarcoidosis.

Parathyroid-hormone-related protein (PTHrP) is the main mediator of the humoral hypercalcemia of malignancy. It is also detected in many normal adult and fetal tissues. Altered calcium metabolism occurs in sarcoidosis, and two cases of sarcoidosis with hypercalcemia and elevated plasma PTHrP are described. An archival study of 20 lymph node biopsies with the pathological diagnosis of sarcoidosis was performed. Immunohistochemistry using a polyclonal antiserum to human PTHrP and in situ hybridization using a riboprobe to human PTHrP were performed on the lymph node biopsies. Immunohistochemistry for PTHrP was also performed on the biopsies from the two cases with elevated plasma levels. Immunohistochemical analysis detected PTHrP in macrophages within granulomata in 17 of the 20 (85%) biopsies. In situ hybridization detected a positive signal for messenger RNA in the granulomata of 11 of 19 (58%) biopsies. PTHrP immunoreactivity and PTHrP gene expression are present in sarcoid granulomata. PTHrP may contribute to the hypercalcemia of sarcoidosis.

Nutrition and ecosystems in Sarawak: The role of the areca nut.

The effects of population pressure on agricultural sustainability in the delicate tropical and subtropical ecosystems have often been thought to explain high prevalence rates of malnutrition in rural South-East Asia. However, recent studies in rural Sarawak suggest that processes of modernisation have resulted in increased variations in energy nutritional status in adults. A contributory factor may be consumption of the areca nut (Malay pinang, of the palm Areca catechu). This is thought to influence energy balance through effects on appetite and resting metabolic rate. Body mass index (BMI, kg/m2) data for 325 Iban men and 438 non-pregnant Iban women, measured in 1990 and again in 1996, have been analysed in relation to areca use, smoking behaviour, socio-economic status, and reported morbidity. Body composition derived from skinfold thickness measurements for 313 men and 382 women was also analysed. The results suggest that use of areca nut is associated with significantly lower age-related increments in BMI and percentage body fat in women after allowing for age, smoking, reported morbidity, and confounding socio-economic factors. Therefore, the impact of recent economic and social development seen in rising prevalences of 'over-nutrition' may be modulated by use of the areca nut.

Anthropometric status and resting metabolic rate in users of the areca nut and smokers of tobacco in rural Sarawak.

The areca nut is chewed by many of the world's population, mainly in South and Southeast Asia. Anthropometric data for 458 Sarawaki adults aged over 24 years, measured both in 1990 and in 1996, were examined in relation to use of tobacco and areca nut. Compared to non-smokers, smoking men were significantly taller and slightly (not significantly) thinner in both years, while smoking women were thinner in 1990 and slightly (not significantly) thinner in 1996. In both sexes there was an increase in the mean and range of body mass index (BMI, W/H2) over the 6-year interval. Smoking women showed a significantly smaller increment in BMI after allowing for areca nut use, which was associated with a similar trend, and this finding depended on including areca use in the model. The trend for men was similar. Possible effects of areca use could reflect variation in 'affluence' or conservatism, or appetite suppression. However, resting metabolic rate in 54 men and 70 women aged 24-60 years was associated with areca use. This association appeared to be mediated by the maximum room temperature of the 24 h preceding measurement. In women, a significant curvilinear association of RMR with maximum temperature was found in users of areca nut but not in non-users. In men, RMR was 7% higher (p < 0.05) in users of areca nut than in non-users, after allowing for age, height, weight, the sum of four skinfold thicknesses, and haemoglobin, but the association with maximum temperature was similar in both groups. It is speculated that constituents of areca nut modulate thermoregulatory pathways, resulting in prolonged temperature-dependent and hyperthermic heat production in this population; that males are more responsive to this effect than females; and that by this mechanism, and possibly also through centrally mediated effects on appetite for food, areca use could contribute to long-term variation in energy balance represented by change in BMI.

Two families with an autosomal dominant inheritance pattern for papillary carcinoma of the thyroid.

BACKGROUND: Papillary carcinoma of the thyroid (PTC) is the most prevalent malignancy of the thyroid gland. Although the majority of lesions are sporadic tumors, an established relationship exists between familial adenomatous polyposis (FAP) and PTC. Moreover, some authors postulate the existence of familial PTC as a distinct entity. Evidence for this is limited, however, there being few well characterized descriptions of pedigrees with high prevalence of PTC. AIMS: The objective of the present study was to examine an apparent heritable predisposition to PTC occurring in two Tasmanian families in which PTC occurs commonly. METHODS: Pedigree charts were constructed for both families and the medical records of the members reviewed. RESULTS: In Pedigree I, 7 of 25 members had PTC (6 of these had coexisting multinodular goiter (MNG), and 11 others had MNG. In Pedigree II, identical male twins and their daughters had PTC. CONCLUSIONS: In both families there is evidence of autosomal dominant inheritance of PTC. The association of PTC with MNG suggests a possible role for MNG in tumor pathogenesis in hereditary PTC. The majority of the patients were diagnosed with PTC before commencement of prospective screening, indicating clinically relevant disease in the families described.

Effects of sodium bicarbonate and sodium chloride on the elimination of etorphine in equine urine.

The combination of large doses of sodium bicarbonate and the potent narcotic, etorphine, has reportedly been given to racehorses in attempts to improve their performance and also to "mask" the presence of etorphine in urine samples. The increased urinary output and pH associated with sodium bicarbonate (approximately 500 g) administration may reduce the urinary concentration of etorphine, making it more difficult to detect. Our experiment was designed to examine the effects of this combination. Six Thoroughbred horses were used in a latin-square design with three horse pairs and three treatments consisting of the following: etorphine (20 micrograms), etorphine (20 micrograms) plus sodium bicarbonate (1.0 g/kg), and etorphine (20 micrograms) plus sodium chloride (0.7 g/kg). Sodium chloride was used to distinguish between the urinary alkalinizing effects of sodium bicarbonate and the diuretic effects associated with the large electrolyte load. Venous blood and urine samples were collected prior to and for 24 h post-treatment. Sodium bicarbonate produced a significant metabolic alkalosis and an increase in urine pH. Both sodium bicarbonate and sodium chloride produced a profound diuresis. After sodium bicarbonate and sodium chloride treatments, the urinary concentration of etorphine, measured by radioimmunoassay (RIA), was reduced and in some cases could not be detected. Extraction of the urine samples, prior to RIA analysis, increased the sensitivity of the assay and in most cases gave a positive result. We conclude that the coadministration of etorphine and sodium bicarbonate or sodium chloride can make the detection of etorphine more difficult because of the dilutional effects associated with the administration of a large electrolyte load.

Occurrence of (E)-4-hydroxy-2-nonenal in plasma and synovial fluid of patients with rheumatoid arthritis and osteoarthritis.

(E)-4-Hydroxy-2-nonenal (HNE), a cytotoxic propagation product of lipid peroxidation, is present in the synovial fluid (0.54 (0.19) mumol/l; mean (SE), n = 9) and plasma (0.34 (0.09) mumol/l, n = 9) of patients with rheumatoid arthritis. This compound was also found in the synovial fluid (0.24 (0.19) mumol/l, n = 9) and plasma (0.09 (0.03) mumol/l, n = 9) of patients with osteoarthritis. The concentration of HNE in the plasma of patients with rheumatoid arthritis was significantly greater than in patients with osteoarthritis.

Gas chromatographic mass-specific investigation of dextromoramide (Palfium) metabolism in the horse.

Dextromoramide (Palfium) was given by intravenous injection to a Thoroughbred horse at a dosage of 20 mg and urine was collected 2, 4, 6 and 8 h after drug administration. Enzymatic hydrolysis of the urine followed by solvent extraction gave a residue which was back-extracted into 0.1 M sulphuric acid. After basification to pH 9 and solvent extraction, the resulting residue was submitted to gas chromatographic-mass spectrometric analysis. Both electron-impact and ammonia chemical-ionization mass spectra were recorded and, based on the observed fragmentation patterns, the principal metabolites in horse urine were shown to be 2,2-diphenyl-3-methyl-4-morpholinobutyramide (compound 2) and the product of hydroxylation of one phenyl ring in dextromoramide (compound 3), respectively. The electron-impact mass spectra of compounds 2 and 3, and of their derivatisation products from oncolumn methylation in the gas chromatograph, are reported.