GD2-CAR T cell therapy for H3K27M-mutated diffuse midline gliomas.

Diffuse intrinsic pontine glioma (DIPG) and other H3K27M-mutated diffuse midline gliomas (DMGs) are universally lethal paediatric tumours of the central nervous system1. We have previously shown that the disialoganglioside GD2 is highly expressed on H3K27M-mutated glioma cells and have demonstrated promising preclinical efficacy of GD2-directed chimeric antigen receptor (CAR) T cells2, providing the rationale for a first-in-human phase I clinical trial (NCT04196413). Because CAR T cell-induced brainstem inflammation can result in obstructive hydrocephalus, increased intracranial pressure and dangerous tissue shifts, neurocritical care precautions were incorporated. Here we present the clinical experience from the first four patients with H3K27M-mutated DIPG or spinal cord DMG treated with GD2-CAR T cells at dose level 1 (1 × 106 GD2-CAR T cells per kg administered intravenously). Patients who exhibited clinical benefit were eligible for subsequent GD2-CAR T cell infusions administered intracerebroventricularly3. Toxicity was largely related to the location of the tumour and was reversible with intensive supportive care. On-target, off-tumour toxicity was not observed. Three of four patients exhibited clinical and radiographic improvement. Pro-inflammatory cytokine levels were increased in the plasma and cerebrospinal fluid. Transcriptomic analyses of 65,598 single cells from CAR T cell products and cerebrospinal fluid elucidate heterogeneity in response between participants and administration routes. These early results underscore the promise of this therapeutic approach for patients with H3K27M-mutated DIPG or spinal cord DMG.

Sequential Stem Cell-Kidney Transplantation in Schimke Immuno-osseous Dysplasia.

Lifelong immunosuppression is required for allograft survival after kidney transplantation but may not ultimately prevent allograft loss resulting from chronic rejection. We developed an approach that attempts to abrogate immune rejection and the need for post-transplantation immunosuppression in three patients with Schimke immuno-osseous dysplasia who had both T-cell immunodeficiency and renal failure. Each patient received sequential transplants of αß T-cell-depleted and CD19 B-cell-depleted haploidentical hematopoietic stem cells and a kidney from the same donor. Full donor hematopoietic chimerism and functional ex vivo T-cell tolerance was achieved, and the patients continued to have normal renal function without immunosuppression at 22 to 34 months after kidney transplantation. (Funded by the Kruzn for a Kure Foundation.).

Successful enteral administration of crushed posaconazole delayed-release tablets in children.

Erratic absorption of posaconazole oral suspension necessitates frequent dosing and administration with meals or supplements. Alternative enteral formulations are desirable for patients intolerant to enteral nutrition. Crushed posaconazole delayed-release tablets (POS-DRT) show promise in adults; limited evidence exists in children. We used crushed POS-DRT in 10 encounters with nine pediatric patients, achieving target POS concentrations in 90% of encounters. This highlights crushed POS-DRT as a potential enteral option for pediatric antifungal prophylaxis and treatment.

Rational Alternatives to Fludarabine and Cyclophosphamide-Based Pre-CAR Lymphodepleting Regimens in the Pediatric and Young Adult B-ALL Setting.

PURPOSE OF REVIEW: Lymphodepleting chemotherapy (LD) has emerged as a key determinant of chimeric antigen receptor T cell (CAR) efficacy across pediatric/adult B cell malignancies. Clinical trials demonstrate the superiority of fludarabine/cyclophosphamide (Flu/Cy) regimens, resulting in the adoption of Flu/Cy as the pre-CAR LD standard. In the context of a global fludarabine shortage, consideration of alternative regimens is timely, yet limited clinical data exists, specifically in the pediatric B-ALL CAR setting. RECENT FINDINGS: Bendamustine has been used as an effective LD prior to CD19-CAR in adult lymphoma. Although use in the pediatric CAR setting is limited, tolerability has been established in pediatric Hodgkin's lymphoma. Clofarabine is a purine nucleoside analog with mechanistic overlap with fludarabine; however, toxicity is high in the upfront leukemia setting, and thus use as an LD pre-CAR should be pursued with caution. We review the experience using bendamustine and clofarabine to serve as a resource when considering LD regimens as an alternative to fludarabine for pediatric B-ALL.

Justice and equity in pragmatic clinical trials: Considerations for pain research within integrated health systems.

Introduction: Pragmatic clinical trials (PCTs) can overcome implementation challenges for bringing evidence-based therapies to people living with pain and co-occurring conditions, providing actionable information for patients, providers, health systems, and policy makers. All studies, including those conducted within health systems that have a history of advancing equitable care, should make efforts to address justice and equity. Methods: Drawing from collective experience within pragmatic pain clinical trials networks, and synthesizing relevant literature, our multidisciplinary working group examined challenges related to integrating justice and equity into pragmatic pain management research conducted in large, integrated health systems. Our analysis draws from military and veteran health system contexts but offers strategies to consider throughout the lifecycle of pragmatic research more widely. Results: We found that PCTs present a unique opportunity to address major influences on health inequities by occupying a space between research, healthcare delivery, and the complexities of everyday life. We highlight key challenges that require attention to support complementary advancement of justice and equity via pragmatic research, offering several strategies that can be pursued. Conclusions: Efforts are needed to engage diverse stakeholders broadly and creatively in PCTs, such as through dedicated health equity working groups and other collaborative relationships with stakeholders, to support robust and inclusive approaches to research design and implementation across study settings. These considerations, while essential to pain management research, offer important opportunities toward achieving more equitable healthcare and health systems to benefit people living with pain and co-occurring conditions.

DNA binding by the ETS protein TEL (ETV6) is regulated by autoinhibition and self-association.

The ETS protein TEL, a transcriptional repressor, contains a PNT domain that, as an isolated fragment in vitro, self-associates to form a head-to-tail polymer. How such polymerization might affect the DNA-binding properties of full-length TEL is unclear. Here we report that monomeric TEL binds to a consensus ETS site with unusually low affinity (K(d) = 2.8 x 10(-8) M). A deletion analysis demonstrated that the low affinity was caused by a C-terminal inhibitory domain (CID) that attenuates DNA binding by approximately 10-fold. An NMR spectroscopically derived structure of a TEL fragment, deposited in the Protein Data Bank, revealed that the CID consists of two alpha-helices, one of which appears to block the DNA binding surface of the TEL ETS domain. Based on this structure, we substituted two conserved glutamic acids (Glu-431 and Glu-434) with alanines and found that this activated DNA binding and enhanced trypsin sensitivity in the CID. We propose that TEL displays a conformational equilibrium between inhibited and activated states and that electrostatic interactions involving these negatively charged residues play a role in stabilizing the inhibited conformation. Using a TEL dimer as a model polymer, we show that self-association facilitates cooperative binding to DNA. Cooperativity was observed on DNA duplexes containing tandem consensus ETS sites at variable spacing and orientations, suggesting flexibility in the region of TEL linking its self-associating PNT domain and DNA-binding ETS domain. We speculate that TEL compensates for the low affinity, which is caused by autoinhibition, by binding to DNA as a cooperative polymer.

Random forests for verbal autopsy analysis: multisite validation study using clinical diagnostic gold standards.

BACKGROUND: Computer-coded verbal autopsy (CCVA) is a promising alternative to the standard approach of physician-certified verbal autopsy (PCVA), because of its high speed, low cost, and reliability. This study introduces a new CCVA technique and validates its performance using defined clinical diagnostic criteria as a gold standard for a multisite sample of 12,542 verbal autopsies (VAs). METHODS: The Random Forest (RF) Method from machine learning (ML) was adapted to predict cause of death by training random forests to distinguish between each pair of causes, and then combining the results through a novel ranking technique. We assessed quality of the new method at the individual level using chance-corrected concordance and at the population level using cause-specific mortality fraction (CSMF) accuracy as well as linear regression. We also compared the quality of RF to PCVA for all of these metrics. We performed this analysis separately for adult, child, and neonatal VAs. We also assessed the variation in performance with and without household recall of health care experience (HCE). RESULTS: For all metrics, for all settings, RF was as good as or better than PCVA, with the exception of a nonsignificantly lower CSMF accuracy for neonates with HCE information. With HCE, the chance-corrected concordance of RF was 3.4 percentage points higher for adults, 3.2 percentage points higher for children, and 1.6 percentage points higher for neonates. The CSMF accuracy was 0.097 higher for adults, 0.097 higher for children, and 0.007 lower for neonates. Without HCE, the chance-corrected concordance of RF was 8.1 percentage points higher than PCVA for adults, 10.2 percentage points higher for children, and 5.9 percentage points higher for neonates. The CSMF accuracy was higher for RF by 0.102 for adults, 0.131 for children, and 0.025 for neonates. CONCLUSIONS: We found that our RF Method outperformed the PCVA method in terms of chance-corrected concordance and CSMF accuracy for adult and child VA with and without HCE and for neonatal VA without HCE. It is also preferable to PCVA in terms of time and cost. Therefore, we recommend it as the technique of choice for analyzing past and current verbal autopsies.

Exploring metacognitive accuracy in visual search.

For decades, researchers have examined visual search. Much of this work has focused on the factors (e.g., movement, set size, luminance, distractor features and proximity) that influence search speed. However, no research has explored whether people are aware of the influence of these factors. For instance, increases in set size will typically slow down target detection; yet no research has measured participants' metacognitive awareness of this phenomenon. The present research explores this area by integrating a visual search task with a metacognitive monitoring paradigm. All of the explored factors influenced search latency. However, all of the factors except target presence influenced ratings. Saliency and suppression are discussed as two possible explanations for the results. Future directions for extending the theory and the practical benefits of this research are also outlined.

Challenges in the control of neglected insect vector diseases of human importance in the Anglo-Caribbean.

INTRODUCTION: Neglected tropical diseases (NTDs) in developing countries like the Caribbean, negatively affect multiple income-generating sectors, including the tourism industry upon which island states are highly dependent. Insect-transmitted NTDs include, but are not limited to, malaria, dengue and lymphatic filariasis. Control measures for these disease, are often ignored because of the associated cost. Many of the developing country members are thus retained in a financially crippling cycle, balancing the cost of prophylactic measures with that of controlling an outbreak.The purpose of the paper is to bring awareness to NTDs transmitted by insects of importance to humans, and to assess factors affecting such control, in the English-speaking Caribbean. METHOD: Comprehensive literature review on reports pertaining to NTDs transmitted by insects in the Caribbean and Latin America was conducted. Data search was carried out on PubMed, and WHO and PAHO websites. RESULTS AND CONCLUSION: Potential risk factors for NTDs transmitted by arthropods in the English-speaking Caribbean are summarised. The mosquito appears to be the main insect-vector of human importance within the region of concern. Arthropod-vectors of diseases of veterinary importance are also relevant because they affect the livelihood of farmers, in highly agriculture based economies. Other NTDs may also be in circulation gauged by the presence of antibodies in Caribbean individuals. However, routine diagnostic tests for specific diseases are expensive and tests may not be conducted when diseases are not prevalent in the population. It appears that only a few English-speaking Caribbean countries have examined secondary reservoirs of pathogens or assessed the effectivity of their insect control methods. As such, disease risk assessment appears incomplete. Although continuous control is financially demanding, an integrated and multisectoral approach might help to deflect the cost. Such interventions are now being promoted by health agencies within the region and various countries are creating and exploring the use of novel tools to be incorporated in their insect-vector control programmes.

Association of Tissue Abiraterone Levels and SLCO Genotype with Intraprostatic Steroids and Pathologic Response in Men with High-Risk Localized Prostate Cancer.

Purpose: Germline variation in solute carrier organic anion (SLCO) genes influences cellular steroid uptake and is associated with prostate cancer outcomes. We hypothesized that, due to its steroidal structure, the CYP17A inhibitor abiraterone may undergo transport by SLCO-encoded transporters and that SLCO gene variation may influence intracellular abiraterone levels and outcomes.Experimental Design: Steroid and abiraterone levels were measured in serum and tissue from 58 men with localized prostate cancer in a clinical trial of LHRH agonist plus abiraterone acetate plus prednisone for 24 weeks prior to prostatectomy. Germline DNA was genotyped for 13 SNPs in six SLCO genes.Results: Abiraterone levels spanned a broad range (serum median 28 ng/mL, 108 nmol/L; tissue median 77 ng/mL, 271 nmol/L) and were correlated (r = 0.355, P = 0.001). Levels correlated positively with steroids upstream of CYP17A (pregnenolone, progesterone), and inversely with steroids downstream of CYP17A (DHEA, AED, testosterone). Serum PSA and tumor volumes were higher in men with undetectable versus detectable tissue abiraterone at prostatectomy (median 0.10 vs. 0.03 ng/dL, P = 0.02; 1.28 vs. 0.44 cc, P = 0.09, respectively). SNPs in SLCO2B1 associated with significant differences in tissue abiraterone (rs1789693, P = 0.0008; rs12422149, P = 0.03) and higher rates of minimal residual disease (tumor volume < 0.5 cc; rs1789693, 67% vs. 27%, P = 0.009; rs1077858, 46% vs. 0%, P = 0.03). LNCaP cells expressing SLCO2B1 showed two- to fourfold higher abiraterone levels compared with vector controls (P < 0.05).Conclusions: Intraprostatic abiraterone levels and genetic variation in SLCO genes are associated with pathologic responses in high-risk localized prostate cancer. Variation in SLCO genes may serve as predictors of response to abiraterone treatment. Clin Cancer Res; 23(16); 4592-601. ©2017 AACR.

Transplantation of benthic species to mitigate impacts of coastal development in Jamaica.

Maintaining regional competitiveness and economic viability for Port Bustamante - Kingston Harbour, Jamaica, required improved accessibility to "Post Panamax" (too large to pass through the Panama Canal) container vessels. Removal of the northern portion of the shallow coral reef at Rackham's Cay, which was partially obstructing the western end of the east ship channel, was proposed. This aesthetically valuable reef was used by local fishermen and comprises part of the declared Palisadoes - Port Royal Protected Area. The proposal to transplant certain of the benthic species was advanced to mitigate loss of viable reef components. Between December 2001 and February 2002, sixty thousand items, consisting of reef building massive and branching corals; gorgonians; urchins (Diadema and Tripneustes spp.) and Thalassia meristems were relocated. During dredging, sedimentation rates from suspended solids in the water column were 0.003 g/cm(2)/day at the control site and 0.008 g/cm(2)/day at the dredge site. Coral cover in the relocation area increased from 15% to 20% while bare substrate decreased from 27% to 21%. This paper documents the mitigation required; some factors controlling the ecology of Rackham's Cay reef, the methodology of the relocation process; and the level of post-dredging survivorship of relocated corals. Political and economic realities of some proposed developments often override ecological considerations. Transplantation of important marine benthic species although time consuming, technically challenging, and expensive, may be one way for developers and ecologists to achieve sometimes disparate goals. This project cost US$1.7 million. The "items" moved were neither unique nor endemic and remain vulnerable to natural and anthropogenic impacts. This project increased public awareness and interest regarding the ecological and economic importance of reef ecosystems. It is anticipated that future coastal and inland developments will benefit from the lessons taught by these mitigative interventions.

Androgen action and metabolism in prostate cancer.

The transcriptional programs regulated through the activity of the androgen receptor (AR) modulate normal prostate development and the maintenance of prostatic functions at maturity. AR signaling also controls key survival and growth functions operative in prostate cancer. Inhibiting the AR program remains the key target in the treatment of advanced prostate cancer, and suppressing AR also holds great potential for preventing the development or progression of early stage prostate cancer. In this review, we detail molecular mechanisms of AR activity, cellular components contributing to the maintenance of AR signaling despite AR-ligand suppression, and discuss treatment strategies designed to target components of resistance to AR-directed therapeutics.

Autoinhibition of ETV6 (TEL) DNA binding: appended helices sterically block the ETS domain.

ETV6 (or TEL), a transcriptional repressor belonging to the ETS family, is frequently involved in chromosomal translocations linked with human cancers. It displays a DNA-binding mode distinct from other ETS proteins due to the presence of a self-associating PNT domain. In this study, we used NMR spectroscopy to dissect the structural and dynamic bases for the autoinhibition of ETV6 DNA binding by sequences C-terminal to its ETS domain. The C-terminal inhibitory domain (CID) contains two helices, H4 and H5, which sterically block the DNA-binding interface of the ETS domain. Importantly, these appended helices are only marginally stable as revealed by amide hydrogen exchange and (15)N relaxation measurements. The CID is thus poised to undergo a facile conformational change as required for DNA binding. The CID also dampens millisecond timescale motions of the ETS domain hypothesized to be critical for the recognition of specific ETS target sequences. This work illustrates the use of appended sequences on conserved structural domains to generate biological diversity and complements previous studies of the allosteric mechanism of ETS1 autoinhibition to reveal both common and divergent features underlying the regulation of DNA binding by ETS transcription factors.

Recurring patterns in the songs of humpback whales (Megaptera novaeangliae).

Humpback whales, unlike most mammalian species, learn new songs as adults. Populations of singers progressively and collectively change the sounds and patterns within their songs throughout their lives and across generations. In this study, humpback whale songs recorded in Hawaii from 1985 to 1995 were analyzed using self-organizing maps (SOMs) to classify the sounds within songs, and to identify sound patterns that were present across multiple years. These analyses supported the hypothesis that recurring, persistent patterns exist within whale songs, and that these patterns are defined at least in part by acoustic relationships between adjacent sounds within songs. Sound classification based on acoustic differences between adjacent sounds yielded patterns within songs that were more consistent from year to year than classifications based on the properties of single sounds. Maintenance of fixed ratios of acoustic modulation across sounds, despite large variations in individual sounds, suggests intrinsic constraints on how sounds change within songs. Such acoustically invariant cues may enable whales to recognize and assess variations in songs despite propagation-related distortion of individual sounds and yearly changes in songs.

Determinants of national diarrheal disease burden.

Diarrheal illness is a leading cause of child mortality in developing nations. Previous longitudinal studies have attempted to identify the factors that contribute to child mortality, but few have examined the determinants of diarrheal illness at a country level. Here we demonstrate the use of Classification and Regression Trees (CART) to predict diarrheal illness from a 192-country data set of country-level attributes and compare the performance of CART with a linear regression model. The CART model identifies improvements in rural sanitation as the most important spending priority for reducing diarrheal illness. We estimate that reducing unmet rural sanitation need worldwide by 65% would save the equivalent of 1.2 million lives annually.

The results of long term coral reef monitoring at three locations in Jamaica: Monkey Island, "Gorgo City" and Southeast Cay / Resultados del monitoreo a largo plazo en los arrecifes de coral en tres lugares de Jamaica: Isla Monkey, "Ciudad Gorgo" y Cayo Sureste

The global and regional impacts of climate change are having devastating consequences on the coral reef ecosystems of the Caribbean. Long term monitoring are important tool for assessing reef health. Monitoring was established in 2000 in the Bahamas, Belize and Jamaica. Following the pilot project, the program was institutionalized in Jamaica and monitoring was conducted on eight occasions from 2000 to 2010. Monkey Island and “Gorgo City” near Discovery Bay (both on the north coast) and Southeast Cay at Port Royal on the south coast were selected. Macroalgae dominated the benthic substrate. Monkey Island and “Gorgo City” had the highest coral cover. Porites astreoides, Montastraea spp., Porites porities, Siderastrea siderea, and Agaricia agaricites were the most common species. Data from this programme have been used in local and regional coral reef assessment and management initiatives.

Los impactos regionales y globales del cambio climático están teniendo consecuencias devastadoras en los ecosistemas de arrecifes de coral en el Caribe. Se establecieron monitoreos en el 2000 en Las Bahamas, Belice y Jamaica. Siguiendo el proyecto piloto, el programa se institucionalizó en Jamaica y el monitoreo se llevó a cabo en ocho ocasiones del 2000 al 2010. Se seleccionaron los sitios: Isla Monkey, “Ciudad Gorgo “ cerca de la Bahía Discovery (ambos en la costa norte) y el Cayo Sureste en el Puerto Royal en el sur de la costa. Las macroalgas dominaban el sustrato bentónico. Isla Monkey y “Ciudad Gorgo” tuvieron la mayor cobertura de coral. Porites astreoides, Montastraea spp, Porites porities, Siderastrea siderea, y Agaricia agaricites representan las especies de corales más frecuentes. Los datos de este programa se han utilizado en las iniciativas de evaluación y manejo de arrecifes de coral locales y regionales.

Acoustic cues available for ranging by humpback whales.

Field measurements of sound propagation in a humpback whale habitat were collected to identify cues that a humpback whale might use to estimate its distance from sound sources. The data show that spectral cues are sufficient for estimating the relative distance a sound has traveled in such environments, and that several other cues may also provide useful information. It is suggested that listening humpback whales may use multiple cues in parallel to determine the range to singing whales.