Fifteen years of shared care for paediatric oncology, haematology and palliative patients across Queensland: The role of Regional Case Managers.

OBJECTIVE: A shared care model was implemented in 2006 in Queensland to facilitate paediatric oncology, haematology and palliative care patients receiving care as close to home as possible. Following initial diagnosis, care planning and treatment at the tertiary children's hospital, appropriate local care was coordinated by Regional Case Managers (RCMs) established at each of 10 Shared Care Units (SCUs). This enabled safe and quality regional care supported by a statewide network providing clinical governance and education. This paper examines learnings from 15 years of this shared care. SETTING: Ten hospitals throughout Queensland facilitated a statewide model of shared care for paediatric oncology, haematology and palliative care patients, supported by a tertiary hub in Brisbane. PARTICIPANTS: Regional Case Managers in Shared Care Units and their supporting staff. DESIGN: Staff from SCUs were surveyed and focus group interviews conducted. RESULTS: The paper reviews the attributes, knowledge and experience required for RCMs. Standards of care were supported through education workshops, clinical placements, chemotherapy credentialing, guidelines and standards. RCMs facilitated communication and information sharing with the tertiary centre, advocated for their cohort of patients locally and streamlined and supported the family's experience of care. CONCLUSION: The RCM role provided invaluable clinical leadership for the care of paediatric oncology, haematology and palliative patients across Queensland. As new treatments evolve, the expertise and coordination provided by the RCMs will be even more critical. Achieving high-quality shared care outcomes is underpinned by the RCMs drive to achieve statewide safety and support for this cohort of children.

Spiritual needs among Koreans and Americans with advanced chronic illnesses: A cultural comparison.

AIMS AND OBJECTIVES: This study aimed to measure the frequency of spiritual needs, identify the factors associated with these needs among Korean and American persons living with an advance chronic illness and compare them from a cross-cultural perspective. BACKGROUND: Persons with serious or life-limiting illnesses often have spiritual needs. Unmet spiritual needs are associated with poor well-being and threaten psychological health. Little is known about how specific spiritual needs vary across cultures. DESIGN: A quantitative, cross-sectional, observational cross-cultural comparison was undertaken. METHODS: The study has been prepared in accordance with the STROBE guidelines. Convenience sampling was used to recruit participants from outpatient clinics in South Korea and Southern California (N = 202). Spiritual needs were measured using the Spiritual Interests Related to Illness Tool (SpIRIT); demographic and illness-related variables were also assessed using paper-and-pencil questionnaires. Data were analysed using various parametric statistical tests, including multiple regression analysis. RESULTS: The findings quantify the intensity and types of spiritual needs that persons living with an advanced chronic illness experience. Furthermore, they show how the spiritual needs of religiously diverse samples of South Koreans and Americans differ. The findings also indicate that self-reported spirituality and religiosity independently explain a substantial amount of the variance in spiritual needs. CONCLUSIONS: In both the samples, spiritual needs were reported and associated with spirituality and religiosity. Although all the eight domains of spiritual needs assessed by the SpIRIT were pertinent to the Korean and American samples, they were prioritised differently. RELEVANCE TO CLINICAL PRACTICE: Screening patients to ascertain how important spirituality or religiosity is to them may help clinicians focus their in-depth assessments on those who report high levels of spirituality or religiosity because these patients may experience the strongest spiritual needs. The SpIRIT shows promise as a measure of diverse spiritual needs.

Effects of busulfan dose escalation on engraftment of infant rhesus monkey hematopoietic stem cells after gene marking by a lentiviral vector.

OBJECTIVE: Non-myeloablative cytoreduction is used in clinical hematopoietic stem cell gene therapy trials to increase engraftment of gene-modified cells. We utilized an infant rhesus monkey model to identify an optimal dosage of busulfan that results in efficient long-term gene marking with minimal toxicities. METHODS: Bone marrow (BM) was harvested, followed by a single 2-hour intravenous infusion of busulfan at escalating dosages of 0 to 160 mg/m(2). CD34(+) cells were immunoselected from BM, transduced overnight with a simian immunodeficiency virus-based lentiviral vector carrying a non-expressed marker gene, and injected intravenously 48 hours post-busulfan administration. Pharmacokinetics were assessed, as well as adverse effects and peripheral blood and BM gene marking. RESULTS: Increasing dosages of busulfan resulted in increased area-under-the-curve (AUC) with some variability at each dosage level, suggesting interindividual variation in clearance. Blood chemistries were normal and no adverse effects were observed as a result of busulfan infusion. At 120 and 160 mg/m(2), transient neutropenia and thrombocytopenia were noted but not lymphopenia. Over the 6 months of study posttransplantation, a busulfan dosage-related increase in gene marking was observed ranging from undetectable (no busulfan) up to 0.1% gene-containing cells in animals achieving the highest busulfan AUC. This corresponds to a more than 100-fold increase in gene marking over the busulfan dosage range studied. CONCLUSIONS: These data indicate that increased gene marking of hematopoietic stem cells can be achieved by escalating busulfan dosages from 40 to 160 mg/m(2) without significant toxicity in infant nonhuman primates.

Specific and stable gene transfer to human embryonic stem cells using pseudotyped lentiviral vectors.

Genetic modification of human embryonic stem cells (hESCs) is an important tool for understanding and influencing their biologic properties. At the present time, lentiviral vectors pseudotyped with the vesicular stomatitis virus G protein (VSV-G) have been most effective for stable gene transfer to hESCs. However, they also efficiently transduce murine embryonic fibroblasts (MEF), used to support the undifferentiated state of many commonly used hESC lines. Transduction of both the MEF as well as hESCs complicates analyses of gene transfer and expression. We made lentiviral vectors pseudotyped with envelope glycoproteins from retroviruses that have been shown to have more restricted transduction ranges and evaluated their specificity. Lentiviral vectors pseudotyped by the envelopes from either the gibbon ape leukemia virus (GALV) or the RD114 feline endogenous virus (RD114) specifically transduced hESCs to similar extents as VSV-G pseudotyped vectors, but did not transduce MEF. In addition, gene modfication by these pseudotyped lentiviral vectors was stably maintained throughout differentiation of hESCs in vitro. These pseudotyped lentiviral vectors may be valuable tools for efficient, specific and stable gene modification of hESCs.

Transduction of green fluorescent protein increased oxidative stress and enhanced sensitivity to cytotoxic drugs in neuroblastoma cell lines.

Green fluorescent protein (GFP) is employed as a selection marker for gene transduction and to track tumor cells. Transduction of enhanced GFP (eGFP) into human neuroblastoma cell lines via a lentiviral vector significantly sensitized CHLA-20 (wild-type and functional TP53), and to a lesser extent CHLA-90 cells (multidrug-resistant, mutant, and nonfunctional TP53) to carboplatin, doxorubicin, etoposide, or melphalan, relative to cells transduced using the cell surface antigen CD80 as a selection marker. Total glutathione (GSH) was significantly up-regulated (1.8- to 2.8-fold) after eGFP (but not CD80) transduction in cell lines with, but not in those lacking, functional p53. Cytotoxicity of GSH depletion by buthionine sulfoximine in CHLA-20 (but not in CHLA-20-eGFP) was diminished by hypoxia (2% O(2)). Thus, oxidative stress produced by GFP selects for cells with up-regulated GSH in a p53-dependent manner, and also enhanced the cytotoxicity of anticancer drugs in neuroblastoma cell lines. Our data suggest caution when employing GFP-transduced cells to assess drug sensitivity and that using a cell surface antigen as a selection marker for gene transduction may perturb cells less than GFP.

Validation of simple visual-analogue thermometer screen for mood complications of cardiovascular disease: the Emotion Thermometers.

OBJECTIVE: Conventional scales may help with the identification of depression but are generally too lengthy for clinical practice and perform poorly against anxiety and distress. We therefore examined the value of a single item NCCN Distress Thermometer and an enhanced visual-analogue method (Emotion Thermometers, ET) that incorporates four emotion thermometers. METHODS: We examined 228 patients with mixed cardiovascular conditions of whom 200 completed questionnaires. 64.5% suffered from cardiomyopathy/congestive heart failure, 9.5% had coronary artery disease, 4.5% had multiple cardiac diagnoses, 3% suffered from hypertension, 2% had rhythm problem, 2% had valve problems and 1.5% were diagnosed with atrial fibrillation. We used DSM-IV criteria to define current depression, the GAD7 to define current anxiety and the HADS-T to define distress. 13% had DSM-IV MDD and 19.1% had major or minor depression using DSM-IV (any depression). There were also 59 people (29.6%) with clinically significant distress and 46 with clinically significant anxiety (23.1%). RESULTS: The optimal accuracy for major depression was either the Depression thermometer (DepT) or the Help thermometer (HelpT), as both performed well. They had a sensitivity and specificity of 73.1%, 89.7% and 84.6%, 85.6%, respectively. The DepT was also best for detecting any DSM-IV depression (sensitivity 68.4% and specificity 93.2%) and HAD-T based distress (sensitivity 79.7% and specificity 82.9%). The Anxiety thermometer (AnxT) performed best against the GAD7 (sensitivity 84.8% and specificity 83.7%). CONCLUSION: Innovative visual-analogue screening tools for mood appear to perform well in cardiovascular settings.

Development of lentiviral vectors with regulated respiratory epithelial expression in vivo.

Development of gene transfer vectors with regulated, lung-specific expression will be a useful tool for studying lung biology and developing gene therapies. In this study we constructed a series of lentiviral vectors with regulatory elements predicted to produce lung-specific transgene expression: the surfactant protein C promoter (SPC) for alveolar epithelial type II cell (AECII) expression, the Clara cell 10-kD protein (CC10) for Clara cell expression in the airway, and the Jaagskiete sheep retrovirus (JSRV) promoter for expression in both cell types. Transgene expression from the SPC and CC10 vectors was restricted to AECII and Clara cell lines, respectively, while expression from the JSRV vector was observed in multiple respiratory and nonrespiratory cell types. After intratracheal delivery of lentivector supernatant to mice, transgene expression was observed in AECII from the SPC lentivector, and in Clara cells from the CC10-promoted lentivector. Transgene expression was not detected in nonrespiratory tissues after intravenous delivery of CC10 and SPC lentiviral vectors to murine recipients. In summary, incorporation of genomic regulatory elements from the SPC and CC10 genes resulted in respiratory specific transgene expression in vitro and in vivo. These vectors will provide a useful tool for the study of lung biology and the development of gene therapies for lung disorders.

Transient gene expression by nonintegrating lentiviral vectors.

Nonintegrating lentiviral (NIL) vectors were produced from HIV-1-based lentiviral vectors by introducing combinations of mutations made to disable the integrase protein itself and to alter the integrase recognition sequences (att) in the viral LTR. NIL vectors with these novel combinations of mutations were used to transduce the human T lymphoid cell line Jurkat and primary human CD34(+) hematopoietic progenitor cells to assess their efficacy measured through transient expression of the enhanced green fluorescent protein (eGFP) reporter gene. The most disabled NIL vectors resulted in initial high levels of eGFP expression (approximately 90% of cells), but expression was transient, diminishing toward background (<0.5%) within less than 1 month. Southern blot analyses of transduced Jurkat cells confirmed the loss of detectable NIL vector sequence (linear form and one- and two-LTR circles) by 1 month. There were low residual levels of integration by NIL vectors (reduced approximately 10(4)-fold compared to wild-type vectors), despite any combination of the engineered changes. Based upon analysis of the sequences of the DNA from the junctions of the vector LTR and cellular chromosomes, these rare integrated NIL vector sequences were not mediated by an integrase-driven mechanism due to reversion of the engineered mutations, but more likely were produced by background recombination events. The development of NIL vectors provides a novel tool for efficient transient gene expression in primary stem cells and hematopoietic and lymphoid cells.

In vivo transduction by intravenous injection of a lentiviral vector expressing human ADA into neonatal ADA gene knockout mice: a novel form of enzyme replacement therapy for ADA deficiency.

Using a mouse model of adenosine deaminase-deficient severe combined immune deficiency syndrome (ADA-deficient SCID), we have developed a noninvasive method of gene transfer for the sustained systemic expression of human ADA as enzyme replacement therapy. The method of delivery is a human immunodeficiency virus 1-based lentiviral vector given systemically by intravenous injection on day 1 to 2 of life. In this article we characterize the biodistribution of the integrated vector, the expression levels of ADA enzyme activity in various tissues, as well as the efficacy of systemic ADA expression to correct the ADA-deficient phenotype in this mouse model. The long-term expression of enzymatically active ADA achieved by this method, primarily from transduction of liver and lung, restored immunologic function and significantly extended survival. These studies illustrate the potential for sustained in vivo production of enzymatically active ADA, as an alternative to therapy by frequent injection of exogenous ADA protein.

Neonatal gene therapy of MPS I mice by intravenous injection of a lentiviral vector.

Mucopolysaccharidosis type I (MPS I) is a lysosomal glycosaminoglycan (GAG) storage disorder caused by deficiency of alpha-l-iduronidase (IDUA). In this study, we evaluated the potential to perform gene therapy for MPS I by direct in vivo injection of a lentiviral vector, using an IDUA gene knockout murine model. We compared the efficacy in newborn versus young adult MPS I mice of a single intravenous injection of the lentiviral vector. The extent of transduction was dose-dependent, with the liver receiving the highest level of vector, but other somatic organs reaching almost the same level. The phenotypic manifestations of disease were partially improved in the mice treated as young adults, but were nearly normalized at every end-point measured in the mice treated as neonates. In the neonatally treated mice, the expressed IDUA activity resulted in decreased GAG storage, prevention of skeletal abnormalities, a more normal gross appearance, and improved survival. Most strikingly, significant levels of IDUA enzyme were produced in the brain of mice treated as neonates, with transduction of neurons at high levels. The sustained expression of enzymatically active IDUA in multiple organs had a significant beneficial effect on the phenotypic abnormalities of MPS I, which may be translated to clinical gene therapy of patients with Hurler disease.

Lentivirus vectors incorporating the immunoglobulin heavy chain enhancer and matrix attachment regions provide position-independent expression in B lymphocytes.

In the present studies we developed lentivirus vectors with regulated, consistent transgene expression in B lymphocytes by incorporating the immunoglobulin heavy chain enhancer (E micro ) with and without associated matrix attachment regions (E micro MAR) into lentivirus vectors. Incorporation of these fragments upstream of phosphoglycerate kinase (PGK) or cytomegalovirus promoters resulted in a two- to threefold increase in enhanced green fluorescent protein (EGFP) mean fluorescence intensity (MFI) in B-lymphoid but not T-lymphoid, myeloid, fibroblast, or carcinoma cell lines. A 1-log increase in EGFP expression was observed in B-lymphoid cells (but not myeloid cells) differentiated from human CD34(+) progenitors in vitro transduced with E micro - and E micro MAR-containing lentivectors. Lastly, we evaluated the expression from the E micro MAR element in mice 2 to 24 weeks posttransplant with transduced hematopoietic stem cells. In mice receiving vectors with the E micro and E micro MAR elements upstream of the PGK promoter, there was a 2- to 10-fold increase in EGFP expression in B cells (but not other cell types). Evaluation of the coefficient of variation of expression among different cell types demonstrated that consistent, position-independent transgene expression was observed exclusively in B cells transduced with the E micro MAR-containing vector and not other cells types or vectors. Proviral genomes with the E micro MAR element had increased chromatin accessibility, which likely contributed to the position independence of expression in B lymphocytes. In summary, incorporation of the E micro MAR element in lentivirus vectors resulted in enhanced, position-independent expression in primary B lymphocytes. These vectors provide a useful tool for the study of B-lymphocyte biology and the development of gene therapy for disorders affecting B lymphocytes, such as immune deficiencies.

Expression from second-generation feline immunodeficiency virus vectors is impaired in human hematopoietic cells.

Vectors based on the feline immunodeficiency virus (FIV) have been developed as an alternative to those based on another lentivirus, human immunodeficiency virus-1 (HIV-1), because of theoretical safety advantages. We compared the efficiency of gene transfer and expression in human and feline hematopoietic progenitors using second-generation HIV-1 and FIV-based vectors. Vector pairs were tested using either human cytomegalovirus or murine phospho-glycerate kinase (PGK) internal promoters and were pseudotyped with the vesicular stomatitis virus G protein (VSV-G). Vector proviral copy numbers were similar in human and feline hematopoietic primary cells and cell lines transduced by HIV-1 or FIV vectors, demonstrating that both vectors are able to transfer genes efficiently to these cell types. HIV-1 vectors were well expressed in human primary hematopoietic cells and cell lines. However, transgene expression from FIV vectors was almost undetectable in human hematopoietic cells. In contrast, the FIV vector was expressed well in primary hematopoietic feline cells and human non-hematopoietic cells, demonstrating that low transgene expression from the FIV vector is a phenomenon specific to human hematopoietic cells. Northern blot analysis demonstrated decreased vector transcript levels in human CEM cells transduced with FIV relative to cells transduced with HIV-1, despite high vector copy numbers. No evidence of vector transcript instability was seen in studies of transduced CEM cells treated with actinomycin D. We conclude that FIV vectors can transfer genes into human hematopoietic cells as effectively as HIV-1 vectors, but that unknown elements in the current FIV backbone inhibit expression from FIV vectors in human hematopoietic cells.