3D histology reveals that immune response to pancreatic precancers is heterogeneous and depends on global pancreas structure.

Pancreatic ductal adenocarcinoma (PDAC) is a highly lethal cancer for which few effective therapies exist. Immunotherapies specifically are ineffective in pancreatic cancer, in part due to its unique stromal and immune microenvironment. Pancreatic intraepithelial neoplasia, or PanIN, is the main precursor lesion to PDAC. Recently it was discovered that PanINs are remarkably abundant in the grossly normal pancreas, suggesting that the vast majority will never progress to cancer. Here, through construction of 48 samples of cm3-sized human pancreas tissue, we profiled the immune microenvironment of 1,476 PanINs in 3D and at single-cell resolution to better understand the early evolution of the pancreatic tumor microenvironment and to determine how inflammation may play a role in cancer progression. We found that bulk pancreatic inflammation strongly correlates to PanIN cell fraction. We found that the immune response around PanINs is highly heterogeneous, with distinct immune hotspots and cold spots that appear and disappear in a span of tens of microns. Immune hotspots generally mark locations of higher grade of dysplasia or locations near acinar atrophy. The immune composition at these hotspots is dominated by naïve, cytotoxic, and regulatory T cells, cancer associated fibroblasts, and tumor associated macrophages, with little similarity to the immune composition around less-inflamed PanINs. By mapping FOXP3+ cells in 3D, we found that regulatory T cells are present at higher density in larger PanIN lesions compared to smaller PanINs, suggesting that the early initiation of PanINs may not exhibit an immunosuppressive response. This analysis demonstrates that while PanINs are common in the pancreases of most individuals, inflammation may play a pivotal role, both at the bulk and the microscopic scale, in demarcating regions of significance in cancer progression.

Phosphodiesterase-5 inhibition collaborates with vaccine-based immunotherapy to reprogram myeloid cells in pancreatic ductal adenocarcinoma.

Pancreatic ductal adenocarcinoma (PDAC) is highly lethal and resistant to immunotherapy. Although immune recognition can be enhanced with immunomodulatory agents including checkpoint inhibitors and vaccines, few patients experience clinical efficacy because the tumor immune microenvironment (TiME) is dominated by immunosuppressive myeloid cells that impose T cell inhibition. Inhibition of phosphodiesterase-5 (PDE5) was reported to downregulate metabolic regulators arginase and inducible NOS in immunosuppressive myeloid cells and enhance immunity against immune-sensitive tumors, including head and neck cancers. We show for the first time to our knowledge that combining a PDE5 inhibitor, tadalafil, with a mesothelin-specific vaccine, anti-programmed cell death protein 1, and anti-cytotoxic T lymphocyte-associated protein 4 yields antitumor efficacy even against immune-resistant PDAC. To determine immunologic advantages conferred by tadalafil, we profiled the TiME using mass cytometry and single-cell RNA-sequencing analysis with Domino to infer intercellular signaling. Our analyses demonstrated that tadalafil reprograms myeloid cells to be less immunosuppressive. Moreover, tadalafil synergized with the vaccine, enhancing T cell activation including mesothelin-specific T cells. Tadalafil treatment was also associated with myeloid/T cell signaling axes important for antitumor responses (e.g., Cxcr3, Il12). Our study shows that PDE5 inhibition combined with vaccine-based immunotherapy promotes pro-inflammatory states of myeloid cells, activation of T cells, and enhanced myeloid/T cell crosstalk to yield antitumor efficacy against immune-resistant PDAC.

A phase 1 study to evaluate the effect of dolutegravir on renal function via measurement of iohexol and para-aminohippurate clearance in healthy subjects.

AIM: Dolutegravir (DTG; S/GSK1349572) is under clinical development as a once daily, unboosted integrase inhibitor for the treatment of HIV infection. The effect of DTG on glomerular filtration rate (GFR), effective renal plasma flow (ERPF), and creatinine clearance (CLcr ) was evaluated in 34 healthy volunteers. METHODS: Subjects received DTG 50 mg (once daily or twice daily) or placebo for 14 days. GFR was measured by iohexol plasma clearance, ERPF was assessed by para-aminohippurate plasma clearance and CLcr was measured by 24 h urine collection. RESULTS: All treatments were generally well tolerated. A modest decrease (10-14%) in CLcr was observed, consistent with clinical study observations. DTG 50 mg once daily and twice daily had no significant effect on GFR or ERPF compared with placebo over 14 days in healthy subjects. CONCLUSIONS: These findings support in vitro data that DTG increases serum creatinine by the benign inhibition of the organic cation transporter 2, which is responsible for tubular secretion of creatinine.

Effect of CP-690,550, an orally active janus kinase inhibitor, on renal function in healthy adult volunteers.

CP-690,550 is a Janus kinase inhibitor being developed to prevent allograft rejection and treat several autoimmune diseases. This study examines the effect of multiple doses of CP-690,550 on renal function in healthy volunteers. Thirty-four volunteers are randomized in a 2:1 ratio in a double-blinded manner to receive CP-690,550 15 mg twice daily or placebo twice daily for 14 days. Volunteers are confined in-house to receive a controlled regimen of water intake and sodium intake of 4 to 5 g/d. The effect of CP-690,550 on glomerular filtration rate (GFR) is measured by iohexol serum clearance, effective renal plasma flow (ERPF) by para-aminohippuric acid (PAH) urinary clearance, and creatinine clearance by 24-hour urine collection on day 1 (predose) and day 15. Steady-state pharmacokinetics and tolerability are assessed. Comparing the day 15 and day 1 (predose) values shows that geometric mean ratios for iohexol serum clearance, PAH urinary clearance, and creatinine clearance are 0.995, 0.925, and 0.948, respectively. When adjusted for the corresponding placebo day ratios, the geometric mean ratios are 1.09, 0.978, and 1.05, respectively. CP-690,550 is well tolerated. These findings indicate that CP-690,550 does not affect GFR, ERPF, or creatinine clearance in healthy volunteers.

Pharmacodynamics of a novel designer natriuretic peptide, CD-NP, in a first-in-human clinical trial in healthy subjects.

CD-NP is a novel chimeric natriuretic peptide (NP) consisting of the 22-amino-acid (AA) human C-type natriuretic peptide (CNP), a venodilating peptide with limited renal actions and minimal effects on blood pressure, and the 15-AA C-terminus of Dendroaspis NP (DNP). The rationale for the design of CD-NP was to enhance the renal actions of CNP, the ligand for natriuretic peptide receptor-B, but without inducing excessive hypotension. Here we report the first-in-human studies for CD-NP, which represent the first successful clinical testing of a chimeric NP demonstrating in normal human volunteers that CD-NP possesses cyclic guanosine monophosphate-activating, natriuretic, and aldosterone-suppressing properties without inducing excessive hypotension, laying the foundation for additional studies on this first-in-class new cardiovascular therapeutic in human heart failure, which are now underway worldwide.

Meta-Analysis of Clinical Trials That Evaluate the Effectiveness of Hospital-Initiated Postdischarge Interventions on Hospital Readmission.

Under pressure to avoid readmissions, hospitals are increasingly employing hospital-initiated postdischarge interventions (HiPDI), such as home visits and follow-up phone calls, to help patients after discharge. This study was conducted to assess the effectiveness of HiPDI on reducing hospital readmissions using a systematic review of clinical trials published between 1990 and 2014. We analyzed twenty articles on HiPDI (from 503 reviewed abstracts) containing 7,952 index hospitalizations followed for a median 3 months (range 1-24) after discharge for readmission. The two most common HiPDI included follow-up phone calls (n = 14, 70%) or home visits (n = 11, 55%); eighty-five percent (n = 17) of studies had multiple HiPDI. In meta-analysis, exposure to HiPDI was associated with a lower likelihood of readmission (odds ratio [OR], 0.8 [95% CI, 0.7-0.9]). Patients receiving ≥2 postdischarge home visits or ≥2 follow-up phone calls had the lowest likelihood of readmission (OR, 0.5 [95% CI, 0.4-0.8]). Hospital-initiated postdischarge interventions seem to have an effect on reducing hospital readmissions. Together, multiple home visits and follow-up phone calls may be the most effective HiPDI to reduce hospital readmission.

SNF5/INI1 deficiency redefines chromatin remodeling complex composition during tumor development.

UNLABELLED: Malignant rhabdoid tumors (MRT), a pediatric cancer that most frequently appears in the kidney and brain, generally lack SNF5 (SMARCB1/INI1), a subunit of the SWI/SNF chromatin-remodeling complex. Recent studies have established that multiple SWI/SNF complexes exist due to the presence or absence of different complex members. Therefore, the effect of SNF5 loss upon SWI/SNF complex formation was investigated in human MRT cells. MRT cells and primary human tumors exhibited reduced levels of many complex proteins. Furthermore, reexpression of SNF5 increased SWI/SNF complex protein levels without concomitant increases in mRNA. Proteomic analysis, using mass spectrometry, of MRT cells before and after SNF5 reexpression indicated the recruitment of different components into the complex along with the expulsion of others. IP-Western blotting confirmed these results and demonstrated similar changes in other MRT cell lines. Finally, reduced expression of SNF5 in normal human fibroblasts led to altered levels of these same complex members. These data establish that SNF5 loss during MRT development alters the repertoire of available SWI/SNF complexes, generally disrupting those associated with cellular differentiation. These findings support a model where SNF5 inactivation blocks the conversion of growth-promoting SWI/SNF complexes to differentiation-inducing ones. Therefore, restoration of these complexes in tumors cells provides an attractive approach for the treatment of MRTs. IMPLICATIONS: SNF5 loss dramatically alters SWI/SNF complex composition and prevents formation of complexes required for cellular differentiation.

Addressing inpatient crowding by smoothing occupancy at children's hospitals.

OBJECTIVE: To quantify the difference in weekday versus weekend occupancy, and the opportunity to smooth inpatient occupancy to reduce crowding at children's hospitals. METHODS: Daily inpatient census data for 39 freestanding, tertiary-care children's hospitals were used to calculate occupancy and to model the impact of reducing variation in occupancy and the change in the number of patients, patient-days, and hospitals exposed to high occupancy pre- and post-smoothing. We also calculated the proportion of weekly admissions that would require different scheduling to achieve within-week smoothing. RESULTS: Overall, hospitals' mean occupancy ranged from 70.9% to 108.1% on weekdays, and 65.7% to 94.9% on weekends. Weekday occupancy exceeded weekend occupancy with a median difference of 8.2% points. The mean post-smoothing reduction in weekly maximum occupancy across all hospitals was 6.6% points. Through smoothing, 39,607 patients from the 39 hospitals were removed from exposure to occupancy levels >95%. To achieve within-week smoothing, a median 2.6% of admissions would have to be scheduled on a different day of the week; this equates to a median of 7.4 patients per week (range: 2.3-14.4). CONCLUSION: Hospitals do have substantial unused capacity, and smoothing occupancy over the course of a week could be a useful strategy that hospitals can use to reduce crowding and protect patients from crowded conditions.

Children's hospitals do not acutely respond to high occupancy.

OBJECTIVE: High hospital occupancy may lead to overcrowding in emergency departments and inpatient units, having an adverse impact on patient care. It is not known how children's hospitals acutely respond to high occupancy. The objective of this study was to describe the frequency, direction, and magnitude of children's hospitals' acute responses to high occupancy. METHODS: Patients who were discharged from 39 children's hospitals that participated in the Pediatric Health Information System database during 2006 were eligible. Midnight census data were used to construct occupancy levels. Acute response to high occupancy was measured by 8 variables, including changes in hospital admissions (4 measures), transfers (2 measures), and length of stay (2 measures). RESULTS: Hospitals were frequently at high occupancy, with 28% of midnights at 85% to 94% occupancy and 42% of midnights at > or =95% occupancy. Whereas half of children's hospitals used occupancy-mitigating responses, there was variability in responses and magnitudes were small. When occupancy was >95%, no more than 8% of hospitals took steps to reduce admissions, 13% increased transfers out, and up to 58% reduced standardized length of stay. Two-day lag response was more common but remained of too small a magnitude to make a difference in hospital crowding. Additional modeling techniques also revealed little response. CONCLUSIONS: We found a low rate of acute response to high occupancy. When there was a response, the magnitude was small.