Indoximod-based chemo-immunotherapy for pediatric brain tumors: A first-in-children phase I trial.

BACKGROUND: Recurrent brain tumors are the leading cause of cancer death in children. Indoleamine 2,3-dioxygenase (IDO) is a targetable metabolic checkpoint that, in preclinical models, inhibits anti-tumor immunity following chemotherapy. METHODS: We conducted a phase I trial (NCT02502708) of the oral IDO-pathway inhibitor indoximod in children with recurrent brain tumors or newly diagnosed diffuse intrinsic pontine glioma (DIPG). Separate dose-finding arms were performed for indoximod in combination with oral temozolomide (200 mg/m2/day x 5 days in 28-day cycles), or with palliative conformal radiation. Blood samples were collected at baseline and monthly for single-cell RNA-sequencing with paired single-cell T cell receptor sequencing. RESULTS: Eighty-one patients were treated with indoximod-based combination therapy. Median follow-up was 52 months (range 39-77 months). Maximum tolerated dose was not reached, and the pediatric dose of indoximod was determined as 19.2 mg/kg/dose, twice daily. Median overall survival was 13.3 months (n = 68, range 0.2-62.7) for all patients with recurrent disease and 14.4 months (n = 13, range 4.7-29.7) for DIPG. The subset of n = 26 patients who showed evidence of objective response (even a partial or mixed response) had over 3-fold longer median OS (25.2 months, range 5.4-61.9, p = 0.006) compared to n = 37 nonresponders (7.3 months, range 0.2-62.7). Four patients remain free of active disease longer than 36 months. Single-cell sequencing confirmed emergence of new circulating CD8 T cell clonotypes with late effector phenotype. CONCLUSIONS: Indoximod was well tolerated and could be safely combined with chemotherapy and radiation. Encouraging preliminary evidence of efficacy supports advancing to Phase II/III trials for pediatric brain tumors.

Dual diagnosis of autosomal dominant polycystic kidney disease and sickle cell disease in a teenage male.

BACKGROUND: Sickle cell disease (SCD) and autosomal dominant polycystic kidney disease (ADPKD) are relatively common genetic conditions with considerable overlap in clinical presentation. In addition to similarities between the signs and symptoms in sickle cell nephropathy and ADPKD, more than half of SCD patients have kidney cysts. The co-occurrence of these two diseases has not been previously reported in the literature. CASE DIAGNOSIS/TREATMENT: A 16-year-old Black male with SCD had bilateral kidney enlargement and multiple simple cysts on ultrasound. Although kidney cysts are significantly more common in individuals affected with SCD, genetic testing with a broad kidney gene panel was performed to explore the possible presence of another underlying genetic cause of his cysts, in addition to SCD. A dual diagnosis of SCD and ADPKD was made following the identification of two copies of the common pathogenic sickle cell HBB variant (c.20A > T, p.Glu7Val) and a pathogenic missense variant in PKD1 (c.8311G > A, p.Glu2771Lys). CONCLUSIONS: SCD and ADPKD differ in pathophysiological mechanisms and treatment regimens. As such, it will be paramount for this teenager to be closely monitored for signs of diminished kidney function and to be co-managed as he transitions to adult care to ensure proper treatment and management. Early identification of individuals with both SCD and a co-occurring condition is crucial to ensuring proper clinical management. Furthermore, identifying and reporting additional patients with SCD and ADPKD dual diagnoses will help us to understand the co-occurring disease course and optimal treatments.

Nuclear Protein in Testis Midline Carcinoma Presenting in an Infant as a Pericardial Mass with Staging by 18F-Fluorodeoxyglucose-positron Emission Tomography/Computed Tomography.

Nuclear protein in testis (NUT) midline carcinoma (NMC) is a rare, aggressive, lethal, epithelioid, poorly differentiated cancer first described in Japan in 1991, unique in that is defined genetically rather than by histological tissue of origin. It usually arises in the body midline and presents as a mass with metastasis. An infant presenting with pneumonia was found to have a pericardial mass, NMC resected, and subsequent staging positron emission tomography (PET) showing residual mediastinal tumor and midline abdominal metastases. Fewer than 100 cases of NMC have been reported in the literature, and PET appears to be the imaging modality of choice in complete staging and evaluation of treatment response.

Population dynamics and range expansion in nine-banded armadillos.

Understanding why certain species can successfully colonize new areas while others do not is a central question in ecology. The nine-banded armadillo (Dasypus novemcinctus) is a conspicuous example of a successful invader, having colonized much of the southern United States in the last 200 years. We used 15 years (1992-2006) of capture-mark-recapture data from a population of armadillos in northern Florida in order to estimate, and examine relationships among, various demographic parameters that may have contributed to this ongoing range expansion. Modeling across a range of values for γ, the probability of juveniles surviving in the population until first capture, we found that population growth rates varied from 0.80 for γ = 0.1, to 1.03 for γ = 1.0. Growth rates approached 1.0 only when γ ≥ 0.80, a situation that might not occur commonly because of the high rate of disappearance of juveniles. Net reproductive rate increased linearly with γ, but life expectancy (estimated at 3 years) was independent of γ. We also found that growth rates were lower during a 3-year period of hardwood removal that removed preferred habitat than in the years preceding or following. Life-table response experiment (LTRE) analysis indicated the decrease in growth rate during logging was primarily due to changes in survival rates of adults. Likewise, elasticity analyses of both deterministic and stochastic population growth rates revealed that survival parameters were more influential on population growth than were those related to reproduction. Collectively, our results are consistent with recent theories regarding biological invasions which posit that populations no longer at the leading edge of range expansion do not exhibit strong positive growth rates, and that high reproductive output is less critical in predicting the likelihood of successful invasion than are life-history strategies that emphasize allocation of resources to future, as opposed to current, reproduction.

A case of Rosai-Dorfman disease in a pediatric patient with cardiac involvement.

Rosai-Dorfman disease (RDD) involves abnormal proliferations of oddly behaving histocytes that are not derived from the Langerhan's Cell linage. These collections tend to occur within lymph nodes, with occasional extra nodal presentation. While RDD is a rare entity itself, extra nodal cases are even more so, with even fewer reporting cardiac involvement, and previously only in adults. This report describes the disease in a pediatric patient who had the unique feature of an extra nodal cardiac mass. The patient, who was known to have sickle cell disease, was initially erroneously thought to have acute chest syndrome. Sudden changes in the patient's status, including development of 3rd degree heart block, demanded investigation with additional imaging. Chest CT revealed a mass arising from the cardiac interatrial septum and encircling the entire thoracic aorta. Imaging features of Rosai-Dorfman disease are nonspecific, complicating the diagnosis. We present this case with discussion of this extremely uncommon entity. We describe the diagnostic methods, the differential diagnosis, and the treatment options.

Molecularly confirmed primary malignant rhabdoid tumor of the urinary bladder: implications of accurate diagnosis.

Malignant rhabdoid tumors (MRTs) are well recognized in the kidney and extrarenal sites such as soft tissues, retroperitoneum, and bladder but are classified as atypical teratoid/rhabdoid tumors in the central nervous system. The unifying features of both extracranial MRT and atypical teratoid/rhabdoid tumors are the exon deletions/mutations of the SMARCB1 (SWI/SNF related, matrix associated, actin dependent regulator of chromatin, subfamily b, member 1) gene in 22q11.23 and resulting loss of SMARCB1/INI1 (integrase interactor 1) protein expression by immunohistochemistry. We herein report a case of extrarenal rhabdoid tumor confined to the bladder in a 3-year-old child, diagnosed by histopathology and confirmed by immunohistochemical and molecular studies. This is only the fourth molecularly proven primary MRT of the bladder to be reported. The patient's peripheral blood was negative for the deletions observed in the tumor, thereby confirming a sporadic origin for the tumor. Given the possible dismal outcome, urgency for definitive diagnosis to institute intensive multimodality therapy, histopathologic differential diagnosis with rhabdomyosarcoma and urothelial carcinoma with rhabdoid features, and lack of consensus management guidelines, oncologists, urologists, and pathologists must be aware of this entity. Evaluation for a germ line SMARCB1 alteration may greatly aid risk stratification and family planning.

Unusual Concentration of Tc-99m methylendiphosphonate in Rhabdomyosarcoma.

Extraosseous accumulation of bone-seeking agents is rare, but has been previously reported in pediatric sarcomas and neuroblastomas. We present an unusual case of a 5-month-old male with an abdominal mass observed clinically by his parents and referring pediatrician. Contrast abdominal computerized tomography confirmed the presence of a large pelvic mass that was diagnosed pathologically as embryonal rhabdomyosarcoma. A bone scintigraphy that was performed for staging of the disease revealed accumulation of the radiopharmaceutical in the tumor. There was no evidence for skeletal metastatic disease. This case further demonstrates the nonspecificity of soft-tissue tumor uptake on bone scintigraphy.

Medulloblastoma with myogenic differentiation: long-term survival in a patient treated with aggressive combination therapy and autologous stem cell transplantation.

Medulloblastoma with myogenic differentiation (MMD) is a rare and aggressive variant of medulloblastoma, occurring predominantly in children. There have been only two case reports of long-term survival previously published. We report a case of long-term disease-free survival in a 21-year-old diagnosed with MMD.

An image is worth a thousand words: why nouns tend to dominate verbs in early word learning.

Nouns are generally easier to learn than verbs (e.g., Bornstein, 2005; Bornstein et al., 2004; Gentner, 1982; Maguire, Hirsh-Pasek, & Golinkoff, 2006). Yet, verbs appear in children's earliest vocabularies, creating a seeming paradox. This paper examines one hypothesis about the difference between noun and verb acquisition. Perhaps the advantage nouns have is not a function of grammatical form class but rather related to a word's imageability. Here, word imageability ratings and form class (nouns and verbs) were correlated with age of acquisition according to the MacArthur-Bates Communicative Development Inventory (CDI) (Fenson et al., 1994). CDI age of acquisition was negatively correlated with words' imageability ratings. Further, a word's imageability contributes to the variance of the word's age of acquisition above and beyond form class, suggesting that at the beginning of word learning, imageability might be a driving factor.

P3 optimization of functional potency, in vivo efficacy and oral bioavailability in 3-aminopyrazinone thrombin inhibitors bearing non-charged groups at the P1 position.

Although the S3 pocket of the thrombin active site is lined with lipophilic amino acid residues, the accommodation of polarity within the lipophilic P3 moiety of small molecule inhibitors is possible provided that the polar functionality is capable of pointing away from the binding pocket outwards toward solvent while simultaneously allowing the lipophilic portion of the P3 ligand to interact with the S3 amino acid residues. Manipulation of this motif provided the means to effect optimization of functional potency, in vivo antithrombotic efficacy and oral bioavailability in a series of 3-aminopyrazinone thrombin inhibitors which contained non-charged groups at the P1 position.

Isolated trisomy 10 in an infant with acute myeloid leukemia: a case report and review of literature.

Trisomy 10 as the sole cytogenetic abnormality in AML is rare, with an incidence rate of < 0.5%. It tends to affect the elderly and is extremely rare in pediatric patients. We describe a case of an 8-month-old Caucasian baby who presented with prominence of left eye and fever without lymphadenopathy or hepatosplenomegaly. Bone survey showed diffuse periosteal reaction in the femur, pelvis, maxillary and orbital bones (with fracture). CBC revealed normal white blood cell count with increased blasts, mild anemia and moderate thrombocytopenia. Bone marrow biopsy showed increased myeloblasts with bilineage dysplasia and 3-4+ reticulin fibrosis. Flow cytometry revealed blasts positive for CD34, CD33, and MPO and negative for CD7, CD13, and HLA-DR. Trisomy 10 was demonstrated by chromosome analysis and fluorescence in-situ hybridization. The patient received induction chemotherapy and achieved complete clinical and hematologic remission at day 28. However, he relapsed after three cycles of chemotherapy. Compared to the two other reported pediatric cases, our patient has some unique features such as much younger age and additional findings such as bilineage dysplasia and bone marrow fibrosis. Both reported cases and our case were classified as AML-M2 indicating that this may be a common subtype in pediatric patients. Bone involvement was present in our patient and one other case and both had similar immunophenotype (CD33+, CD7-). These findings suggest that isolated trisomy 10 may be associated with distinct clinicopathologic features in pediatric AML. Studies on additional patients are needed to establish this association.

Is leprosy spreading among nine-banded armadillos in the southeastern United States?

In the United States, nine-banded armadillo (Dasypus novemcinctus) populations are derived from two sources: (1) a continuous range expansion from Mexico led to western populations, some of which, particularly along the western Gulf Coast and west side of the Mississippi River delta, exhibit persistently high rates of leprosy infection, and (2) a small group of animals released from captivity in Florida gave rise to eastern populations that were all considered leprosy free. Given that western and eastern populations have now merged, an important question becomes, to what extent is leprosy spreading into formerly uninfected populations? To answer this question, we sampled 500 animals from populations in Mississippi, Alabama, and Georgia. Analyses of nuclear microsatellite DNA markers confirmed the historic link between source populations from Texas and Florida, but did not permit resolution of the extent to which these intermediate populations represented eastern versus western gene pools. Prevalence of leprosy was determined by screening blood samples for the presence of antibodies against Mycobacterium leprae and via polymerase chain reaction amplification of armadillo tissues to detect M. leprae DNA. The proportion of infected individuals within each population varied from 0% to 10%. Although rare, a number of positive individuals were identified in eastern sites previously considered uninfected. This indicates leprosy may be spreading eastward and calls into question hypotheses proposing leprosy infection is confined because of ecologic constraints to areas west of the Mississippi River.

The Role of Verbal Repetition in the Development of Infant Speech Preferences From 4 to 14 Months of Age.

Four experiments investigated infants' preferences for age-appropriate and age-inappropriate infant-directed speech (IDS) over adult-directed speech (ADS). Two initial experiments showed that 6-, 10-, and 14-month-olds preferred IDS directed toward younger infants, and 4-, 8-, 10-, and 14-month-olds, but not 6-month-olds, preferred IDS directed toward older infants. In Experiment 3. 6-month-olds preferred IDS directed toward older infants when the frequency of repeated utterances matched IDS to younger infants. In Experiment 4, 6-month-olds preferred repeated IDS utterances over the same IDS utterances organized without repetition. Attention to repeated utterances precedes word segmentation and sensitivity to statistical cues in continuous speech, and might play a role in the discovery of these and other aspects of linguistic structure.

Imageability predicts the age of acquisition of verbs in Chinese children.

Verbs are harder to learn than nouns in English and in many other languages, but are relatively easy to learn in Chinese. This paper evaluates one potential explanation for these findings by examining the construct of imageability, or the ability of a word to produce a mental image. Chinese adults rated the imageability of Chinese words from the Chinese Communicative Development Inventory (Tardif et al., in press). Imageability ratings were a reliable predictor of age of acquisition in Chinese for both nouns and verbs. Furthermore, whereas early Chinese and English nouns do not differ in imageability, verbs receive higher imageability ratings in Chinese than in English. Compared with input frequency, imageability independently accounts for a portion of the variance in age of acquisition (AoA) of verb learning in Chinese and English.

Azaindoles: moderately basic P1 groups for enhancing the selectivity of thrombin inhibitors.

Starting from a 2-amino-6-methylpyridine P1 group and following a strategy of enlarging it whilst reducing its polarity, we have developed a series of potent, moderately basic azaindoles which are intrinsically much more selective for thrombin versus trypsin. Certain pyrazinone acetamide azaindole derivatives have pharmacokinetic parameters after oral administration to dogs, or efficacy in vitro, comparable to an optimized pyrazinone acetamide 2-amino-6-methylpyridine derivative.

Metabolism-directed optimization of 3-aminopyrazinone acetamide thrombin inhibitors. Development of an orally bioavailable series containing P1 and P3 pyridines.

Recent efforts in the field of thrombin inhibitor research have focused on the identification of compounds with good oral bioavailability and pharmacokinetics. In this manuscript we describe a metabolism-based approach to the optimization of the 3-(2-phenethylamino)-6-methylpyrazinone acetamide template (e.g., 1) which resulted in the modification of each of the three principal components (i.e., P1, P2, P3) comprising this series. As a result of these studies, several potent thrombin inhibitors (e.g., 20, 24, 25) were identified which exhibit high levels of oral bioavailability and long plasma half-lives.

Myxedema ascites in the posttransplant setting: case report.

Ascites is a rare but important complication of hypothyroidism. Because of the rarity of the disease and the inconsistency of symptoms associated with hypothyroidism, patients often go undiagnosed for months. Institution of thyroid replacement hormone results in rapid and complete resolution of ascites. Here we present a case of myxedema ascites that presented in a 52-year-old man 4 months after allogeneic bone marrow transplant (BMT). Diagnoses initially considered in the differential included the common post-BMT complications, namely, hepatic veno-occlusive disease, graft vs. host disease, and infection. However, posttransplant patients are also at risk for illnesses unrelated to their underlying diagnosis or transplant procedure, including hypothyroidism. This case illustrates the importance of considering a broad differential diagnosis in posttransplant patients, especially those in whom the clinical course is atypical.