A pilot study of dose-intensified procarbazine, CCNU, vincristine for poor prognosis brain tumors utilizing fibronectin-assisted, retroviral-mediated modification of CD34+ peripheral blood cells with O6-methylguanine DNA methyltransferase.

Administration of chemotherapy is often limited by myelosuppression. Expression of drug-resistance genes in hematopoietic cells has been proposed as a means to decrease the toxicity of cytotoxic agents. In this pilot study, we utilized a retroviral vector expressing methylguanine DNA methyltransferase (MGMT) to transduce hematopoietic progenitors, which were subsequently used in the setting of alkylator therapy (procarbazine, CCNU, vincristine (PCV)) for poor prognosis brain tumors. Granulocyte colony-stimulating factor (G-CSF)-mobilized peripheral blood progenitor cells were collected by apheresis and enriched for CD34+ expression. Nine subjects were infused with CD34+-enriched cells treated in a transduction procedure involving a 4-day exposure to cytokines with vector exposure on days 3 and 4. No major adverse event was related to the gene therapy procedure. Importantly, the engraftment kinetics of the treated product was similar to unmanipulated peripheral blood stem cells, suggesting that the ex vivo manipulation did not significantly reduce engrafting progenitor cell function. Gene-transduced cells were detected in all subjects. Although the level and duration was limited, patients receiving cells transduced using fibronectin 'preloaded' with virus supernatant appeared to show improved in vivo marking frequency. These findings demonstrate the feasibility and safety of utilizing MGMT-transduced CD34+ peripheral blood progenitor cells in the setting of chemotherapy.

Long-term results after early primary repair of tetralogy of Fallot.

OBJECTIVE: Early primary repair of tetralogy of Fallot has been routinely performed at Children's Hospital, Boston, since 1972. We evaluated the long-term outcome of this treatment strategy including the influence of a transannular patch. METHODS: Fifty-seven patients less than 24 months of age (median 8 months) underwent primary repair of tetralogy of Fallot between January 1972 and December 1977. Thirty-one patients had a transannular patch. Survival and freedom from reintervention were determined by the Kaplan-Meier method with 95% confidence intervals. RESULTS: There were 8 early deaths, and 1 patient died 24 years after initial repair. Recent follow-up was obtained for 45 of the 49 long-term survivors (92%). Median follow-up was 23.5 years. Ten patients underwent reintervention, 8 of whom underwent relief of right ventricular outflow tract obstruction. Right ventricular outflow tract obstruction occurred in 6 patients without a transannular patch and 2 with a transannular patch (33% vs 6%, P =.04). One pulmonary valve replacement was performed at another institution 20 years after the repair. Forty-one long-term survivors were in New York Heart Association class I and 4 were in class II. Actuarial survival was 86% at 20 years (95% confidence intervals = 80%-92%). Freedom from reintervention was 93% at 5 years (95% confidence intervals = 87%-99%) and 79% at 20 years (95% confidence intervals = 70%-86%). No significant differences were found between patients with and without a transannular patch (survival, P =.34; freedom from reintervention, P =.09, log-rank tests). CONCLUSIONS: Long-term survival is excellent and the freedom from reintervention is satisfactory after early primary repair of tetralogy of Fallot in the 1970s. Use of a transannular patch does not reduce late survival and is associated with a lower incidence of right ventricular outflow tract obstruction.

A novel fluorometric oligonucleotide assay to measure O( 6)-methylguanine DNA methyltransferase, methylpurine DNA glycosylase, 8-oxoguanine DNA glycosylase and abasic endonuclease activities: DNA repair status in human breast carcinoma cells overexpressing methylpurine DNA glycosylase.

DNA repair status plays a major role in mutagenesis, carcinogenesis and resistance to genotoxic agents. Because DNA repair processes involve multiple enzymatic steps, understanding cellular DNA repair status has required several assay procedures. We have developed a novel in vitro assay that allows quantitative measurement of alkylation repair via O(6)-methylguanine DNA methyltransferase (MGMT) and base excision repair (BER) involving methylpurine DNA glycosylase (MPG), human 8-oxoguanine DNA glycosylase (hOGG1) and yeast and human abasic endonuclease (APN1 and APE/ref-1, respectively) from a single cell extract. This approach involves preparation of cell extracts in a common buffer in which all of the DNA repair proteins are active and the use of fluorometrically labeled oligonucleotide substrates containing DNA lesions specific to each repair protein. This method enables methylation and BER capacities to be determined rapidly from a small amount of starting sample. In addition, the stability of the fluorometric oligonucleotides precludes the substrate variability caused by continual radiolabeling. In this report this technique was applied to human breast carcinoma MDA-MB231 cells overexpressing human MPG in order to assess whether up-regulation of the initial step in BER alters the activity of selected other BER (hOGG1 and APE/ref-1) or direct reversal (MGMT) repair activities.

Modulation of 1,3-bis-(2-chloroethyl)-1-nitrosourea resistance in human tumor cells using hammerhead ribozymes designed to degrade O6-methylguanine DNA methyltransferase mRNA.

O6-Methylguanine DNA Methyltransferase (MGMT) protects tumor cells from the cytotoxic effects of the DNA alkylating agent 1,3-bis-(2-chloroethyl)-1-nitrosourea (BCNU). To improve the therapeutic index of BCNU, biochemical strategies to deplete MGMT activity have been developed. In the present study, a molecular strategy for modulating BCNU resistance was explored using hammerhead ribozymes (Rz) designed to degrade the long-lived MGMT mRNA. The ribozymes were designed against eight GUC sites within the MGMT mRNA. cDNAs of these ribozymes were cloned into an expression vector and then all eight vectors were pooled and stably transfected into HeLa cells. Several HeLa/Rz clones sensitive to a sublethal dose of BCNU were identified using a short-term cell proliferation assay. The ribozyme inserts were amplified from genomic DNA by polymerase chain reaction and sequenced in the BCNU-sensitive clones. The ribozyme inserts Rz161, 178, and 212, targeted against nucleotide 161, 178, and 212, respectively, in the MGMT mRNA, were found to be present in these clones. MGMT activity, Western, and Northern blot analyses revealed that two of the HeLa/Rz clones contained very low levels of MGMT activity, protein, and mRNA. Investigation of CpG methylation within the MGMT promoter indicated that the lack of MGMT expression in these HeLa/Rz clones was not likely due to methylation silencing of the MGMT gene. By colony formation, the cell killing induced by 100 microM BCNU was increased by 2 to 3 logs in the HeLa/Rz clones compared with wild-type HeLa cells.

Comparison of single- versus double-bolus treatments of O(6)-benzylguanine for depletion of O(6)-methylguanine DNA methyltransferase (MGMT) activity in vivo: development of a novel fluorometric oligonucleotide assay for measurement of MGMT activity.

Previous studies have demonstrated that optimal reversal of 1,3-bis(2-chloroethyl)-1-nitrosourea (BCNU) resistance requires complete inactivation of the DNA repair protein O(6)-methylguanine DNA methyltransferase (MGMT) for at least 24 h following BCNU administration. In preparation for clinical trials at this institution, this study was undertaken to compare the efficacy of a conventional single-bolus dose versus double-bolus dose treatments with O(6)-benzylguanine (BG) in depleting MGMT activity in vivo. In xenograft human glioma SF767 tumors, a single 30-mg/kg bolus dose of BG completely inhibited MGMT activity for at least 8 h, but approximately 50% of the basal MGMT activity recovered within 24 h. To sustain the MGMT depletion for 24 h, a second bolus injection of BG at escalating doses was administered 8 h after the first dose. Second bolus doses of 5, 10, and 15 mg/kg BG attenuated the MGMT recovery in a dose-dependent manner compared with the single 30-mg/kg BG dose alone. When the 15-mg/kg BG dose was administered 8 h after the 30-mg/kg initial dose, MGMT activity was completely inactivated in the tumor xenografts for 24 h. This double-bolus BG treatment also depleted MGMT activity in normal murine tissues, including the liver, kidney, lung, brain, spleen, and bone marrow; and the kinetics of MGMT recovery varied among these tissues. When combined with BCNU treatment, the double-bolus BG treatment would be expected to produce greater antitumor activity in future trials than the conventional single-bolus BG treatment.

Protection of hematopoietic cells against combined O6-benzylguanine and chloroethylnitrosourea treatment by mutant forms of O6-methylguanine DNA methyltransferase.

This report demonstrates that expression of the P140A O6-methylguanine DNA methyl transferase (MGMT) mutant via retrovirus-mediated gene transfer leads to significant, but modest, resistance of cells to both 6-benzylguanine (6-BG) depletion and treatment with 1,3-bis (2-chloroethyl)-1-nitrosourea (BCNU). Expression of the P140A/G156A double mutant appeared to be associated with reduced or unstable protein in hematopoietic cells.

The impact of managed care insurance on use of lower-mortality hospitals by children undergoing cardiac surgery in California.

CONTEXT: Managed care plans aggressively seek to contain costs, but few data are available regarding their impact on access to high quality care for their members. OBJECTIVE: To assess the impact of managed care health insurance on use of lower-mortality hospitals for children undergoing heart surgery in California. DESIGN: Retrospective cohort study using state-mandated hospital discharge datasets. SETTING: Pediatric cardiovascular surgical centers in California. PATIENTS: Five thousand seventy-one children admitted for open cardiac surgical procedures during 1992-1994. RESULTS: Hospitals were divided into lower- and higher-mortality groups according to adjusted surgical mortality. Using multivariate logistic regression analysis to control for medical, socioeconomic, demographic, and distance factors, children with managed care insurance were less likely to be admitted to a lower-mortality hospital for surgery relative to children with indemnity insurance (odds ratio:.53; 95% confidence interval:.45,.63). Similar findings resulted when the analysis was stratified by race/ethnicity. In addition, length of stay, a correlate of health care costs, was no longer for children admitted to lower-mortality centers than for those at higher-mortality centers (adjusted difference:.54 days shorter at lower-mortality centers; 95% confidence interval: -1.50,. 41). CONCLUSIONS: During this study, children with managed care insurance had significantly reduced use of lower-mortality hospitals for pediatric heart surgery in California compared with children with indemnity insurance. Further study is necessary to determine the mechanisms of this apparent insurance-specific inequity.

Impact of anatomic closure on somatic growth among small, asymptomatic children with secundum atrial septal defect.

We retrospectively identified 92 children aged

The relationship between managed care insurance and use of lower-mortality hospitals for CABG surgery.

CONTEXT: Explicit information about the quality of coronary artery bypass graft (CABG) surgery has been available for nearly a decade in New York State; however, the extent to which managed care insurance plans direct enrollees to the lowest-mortality CABG surgery hospitals remains unknown. OBJECTIVE: To compare the proportion of patients with managed care insurance and fee-for-service (FFS) insurance who undergo CABG surgery at lower-mortality hospitals. DESIGN: A retrospective cohort study of CABG surgery discharges from 1993 to 1996, using New York Department of Health databases and multivariate analysis to estimate the use of lower-mortality hospitals by patients with different types of health insurance. SETTING: Cardiac surgical centers in New York, of which 14 were classified as lower-mortality hospitals (mean rate, 2.1%) and 17 were classified as higher-mortality hospitals (mean rate, 3.2%). PATIENTS: A total of 58,902 adults older than 17 years who were hospitalized for CABG surgery. Patients were excluded if their CABG surgery was combined with any valve procedure or left ventricular aneurysm resection or if they were younger than 65 years and enrolled in Medicare FFS or Medicare managed care. MAIN OUTCOME MEASURE: Probability of a patient receiving CABG surgery at a lower-mortality hospital. RESULTS: Compared with patients with private FFS insurance (n = 18,905), patients with private managed care insurance (n=7169) and Medicare managed care insurance (n=880) were less likely to receive CABG surgery at a lower-mortality hospital (relative risk [RR] of surgery at a lower-mortality hospital compared with patients with private FFS insurance, 0.77; 95% confidence interval [CI], 0.74-0.81; P<.001; and RR, 0.61; 95% CI, 0.54-0.70; P<.001, respectively, after controlling for multiple potential confounding factors). Patients with Medicare FFS insurance used lower-mortality hospitals at rates more similar to those with private FFS insurance (n = 31,948; RR, 0.95; 95% CI, 0.91-0.98; P=.004). CONCLUSIONS: Patients in New York State with private managed care and Medicare managed care insurance were significantly less likely to use lower-mortality hospitals for CABG surgery compared with patients with private FFS insurance.

Prolonged inhibition of O(6)-methylguanine DNA methyltransferase in human tumor cells by O(6)-benzylguanine in vitro and in vivo.

We previously demonstrated that sustained depletion of methylguanine DNA methyltransferase (MGMT) activity is required for optimal reversal of chloroethylnitrosourea resistance in tumor cells. The purpose of this study was to design O(6)-benzylguanine (BG) treatments that deplete MGMT activity in tumor cells and xenograft tumors in a prolonged manner. When SF767 cells were treated with a bolus dose of BG (25 microM for 1 h), >95% of MGMT activity was depleted but 33% of the activity recovered within 24 h. In contrast, MGMT activity was completely depleted for 24 h when cells were pretreated with a low dose of BG (2.5 microM) for 24 h, followed by the bolus dose and same low-dose treatment for 24 h. This combination regimen of pre- and post-treatments with a bolus dose sensitized cells N,N'-bis(2-chloroethyl)-N-nitrosourea in vitro by approximately 2-fold more than the bolus dose alone. Similar BG treatment with Alzet micro-osmotic pumps produced sustained inhibition of MGMT activity in vivo. In xenograft SF767 tumors, low-dose pre- and post-treatments (8 mg/kg over 24 h) combined with an i.p. bolus dose (80 mg/kg) of BG inhibited >95% of MGMT activity for 24 h after the bolus. The bolus dose alone did not deplete MGMT for 24 h. These results demonstrate that combination low-dose and bolus BG treatment is superior to the bolus dose alone in depleting MGMT activity in a sustained manner in vitro and in vivo. When combined with N,N'-bis(2-chloroethyl)-N-nitrosourea treatment, this BG regimen also should also produce greater antitumor activity than the single bolus dose evaluated clinically.

Retroviral-mediated expression of the P140A, but not P140A/G156A, mutant form of O6-methylguanine DNA methyltransferase protects hematopoietic cells against O6-benzylguanine sensitization to chloroethylnitrosourea treatment.

O(6)-Benzylguanine (6-BG) inactivates mammalian O(6)-methylguanine DNA methyltransferase (MGMT), an important DNA repair protein that protects cells against chloroethylnitrosourea (CENU) cytotoxicity. 6-BG is being tested as an approach to treat CENU-resistant tumors that overexpress endogenous MGMT. However, in addition to restoring CENU tumor cell sensitivity, 6-BG also increases the cytotoxic effects of CENUs on hematopoietic cells. Several 6-BG-resistant human MGMT mutants have been characterized in Escherichia coli and are predicted to protect mammalian cells against the combination of 6-BG and CENU treatment in vivo. Two mutants, P140A and P140A/G156A, demonstrated 20- and 1200-fold more resistance to 6-BG depletion of MGMT activity compared with wild-type MGMT (WTMGMT). Here, we analyzed retroviral vectors that express either WTMGMT, the P140A or P140A/G156A mutant forms of MGMT. Retroviral-infected L1210 hematopoietic cells demonstrated similar levels of RNA in all transduced clones. However, the amount of MGMT protein and DNA repair activity was reduced in clones expressing the P140A/G156A mutant compared with those expressing WTMGMT or P140A. Expression of P140A was associated with a 4- to 8-fold increase in resistance to 6-BG depletion of MGMT in transduced L1210 clones and a 1, 3-bis(2-chloroethyl)-1-nitrosourea IC(50) of 50 microM (compared with 27.5 microM for WTMGMT) in primary murine hematopoietic cells. These results demonstrate the utility of screening 6-BG-resistant MGMT proteins in hematopoietic cells and provide evidence that the P140A mutant form of MGMT generates 6-BG- and CENU-resistant hematopoietic cells. Retrovirus vectors expressing this mutant may be useful in future human gene therapy trials.

AF64A-induced changes in N-myc expression in the LA-N-2 human neuroblastoma cell line are modulated by choline and hemicholinium-3.

Due to AF64A's structural similarity to choline, AF64A can selectively affect cholinergic neurons, which possess a high affinity choline transport system for acetylcholine synthesis. The mechanism by which AF64A selectively produces its cytotoxic effect is unknown. However, based on previous studies that demonstrate that DNA lesions produced by AF64A caused premature termination of N-myc transcription in vitro, it is possible that AF64A may affect the transcription of genes necessary for developmental maintenance in cholinergic cells. Using the LA-N-2 cells as a model to study the effects of AF64A in a purely cholinergic system, we investigated the effects of AF64A on the expression of the N-myc gene and monitored cell growth. AF64A produced a maximal decrease in N-myc mRNA with a return to steady state levels at later time points. Moreover, a decrease in cell numbers in AF64A-treated cells was observed, and these cells did not double in number at their respective doubling time as compared to control. In other studies, a causal relationship between a reduction in N-myc and an inhibition of cell growth and replication has been reported. While these studies do not allow us to conclude that AF64A is specific for N-myc, the data do, nevertheless, suggest that AF64A affects cell growth and/or replication by down-regulating the expression of N-myc which is involved in differentiation and cell growth in neuroblastomas. Presence of choline or hemicholinium-3 prevented the AF64A-induced decrease of N-myc levels by competing with, or inhibiting the choline transport mechanism by which AF64A enters the cell, respectively.

Partial anomalous left pulmonary artery: new evidence on the development of the pulmonary artery sling.

Clinical and angiographic data of a child with a unique form of partial anomalous left pulmonary artery are reported. Because the anomalous pulmonary artery does not run posterior to the trachea, this malformation is not associated with airway obstruction, as are all other forms of anomalous left pulmonary artery described to date. This case strengthens our understanding of the development of the pulmonary artery sling.

Unusual instrument relationship--wrench or turnkey.

An unknown instrument donated to the dental museum, and resembling a dental extraction key, was identified by a patent number found on the instrument. The patent was issued to A. G. H. Andree in May 1921. It relates to an adjustable wrench that can be placed over and turn objects of different diameters and can be adjusted to be used on the right or left side. It was compared to the dental extraction turnkey that was used from the early 1700's to the early 1900's. The resemblance between the two instruments is remarkable. They look and function in a similar manner. Did the idea for the wrench come from a dental turnkey?

Unusual "midseptal" sinus venosus defect.

An unusual case of an interatrial communication similar to a sinus venosus defect associated with an overriding pulmonary venous chamber is reported. There was no direct connection of the pulmonary venous system with either the superior vena cava or the low right atrium, as is usual with sinus venosus defects. This defect may represent the result of a sinus venosus defect associated with cor triatriatum.

Transient myocardial dysfunction in a child with salicylate toxicity.

Aspirin overdose may result in acid-base disturbances, electrolyte abnormalities, pulmonary edema, chemical hepatitis, seizures, and mental status alteration, but myocardial depression has not been reported following aspirin overdose in children. In addition to these more typical features, the 13-month-old boy reported here developed clinical, radiographic, and echocardiographic evidence of myocardial impairment with pulmonary edema and moderately severe global left ventricular dysfunction (estimated shortening fraction of 23%). Complete resolution of the myocardial dysfunction was demonstrated on follow-up echocardiography as the child recovered from the aspirin intoxication. This case suggests that myocardial dysfunction can occur as a result of toxic aspirin ingestion, and that it may contribute to salicylate-induced pulmonary edema.

The role of mRNA stability and transcription in O6-methylguanine DNA methyltransferase (MGMT) expression in Mer+ human tumor cells.

We have recently reported that following depletion of O6-methylguanine DNA methyltransferase (MGMT) activity by acute streptozotocin (STZ) treatment to sensitize innately chloroethylnitrosourea (CENU)-resistant HT-29 cells, the eventual repletion of activity occurs with no concommitant alterations in steady-state MGMT mRNA levels. This suggestion of a potentially stable transcript prompted studies to define the relative contributions of MGMT mRNA stability and transcription to cellular MGMT expression. Northern analysis of MGMT mRNA in actinomycin D-treated HT-29, MR-1 and A2182 cells, ranging in relative MGMT expression from high to low respectively, demonstrates relatively long MGMT mRNA half-lives of > 10-12 h. Cell lines with low and moderate levels of MGMT mRNA appear to have longer mRNA half-lives than those with high levels. Run-on transcription in nuclei isolated from cells with low to moderate MGMT mRNA levels demonstrates undetectable basal MGMT transcription rates. Collectively these data suggest that a very low transcription rate, coupled with a stable mRNA molecule, might result in the translation of pre-existing mRNA molecules. This translation may be responsible for the gradual recovery of MGMT and CENU resistance over 24 h following MGMT depletion.

AF64A-induced cytotoxicity and changes in choline acetyltransferase activity in the LA-N-2 neuroblastoma cell line are modulated by choline and hemicholinium-3.

The cholinergic neurotoxin AF64A (ethylcholine aziridinium) has been used to selectively destroy the cholinergic system. Due to its structural similarity to choline, this compound may be selectively taken up by the cholinergic terminal via the high-affinity choline transport (HAChT) system to produce persistent and selective cholinergic deficits. The mechanism by which it exerts its cholinotoxicity remains to be elucidated. We have examined the effects of AF64A in the human neuroblastoma cell line, LA-N-2, which has an intact sodium-coupled choline uptake system, and is capable of synthesizing acetylcholine (ACh). AF64A (25, 50 and 100 microM) produced dose-dependent increases in cell kill as measured by colony formation assay. The addition of increasing concentrations (10(-5), 10(-4) and 10(-3) M) of choline and hemicholinium-3 (HC-3) protected the cells from the cytotoxic effects of AF64A. At the same doses, AF64A also decreased choline acetyltransferase (ChAT) activity. In the presence of the highest concentration of choline or HC-3 (10(-3) M) which produced complete protection against AF64A's cytotoxicity in the colony formation assay, ChAT activity was restored to control values. These results demonstrate that agents that utilize (i.e., choline) or inhibit (i.e., HC-3) the choline uptake system prevented AF64A-induced cytotoxicity and decreases in ChAT activity, in a manner similar to that which has been observed in chick and rat primary cholinergic cultures in vitro. The LA-N-2 neuroblastoma cell line thus serves well as an in vitro model of the cholinergic neuron and provides a useful system to study the mode of cholinotoxicity induced by AF64A.

In vitro transcription termination by N,N'-bis(2-chloroethyl)-N-nitrosourea-induced DNA lesions.

N,N'-Bis(2-chloroethyl)-N-nitrosourea (BCNU) and its derivatives are chemotherapeutic DNA-damaging agents that generate a variety of monoadducts, intrastrand cross-links, and interstrand cross-links. The cytotoxic potential of the compounds has been linked to their ability to form DNA interstrand cross-links, which presumably inhibit subsequent DNA replication. To address the possibility that BCNU-induced lesions may also influence other DNA-directed actions such as transcription, and to identify the DNA lesions involved, a synthetic DNA template containing phage RNA polymerase promoters at both ends was incubated with BCNU and, after drug removal, transcribed in vitro. For comparison, similar studies were carried out with cis-diammine-dichloroplatinum(II) and trans-diamminedichloroplatinum(II), which are known to induce defined transcription-terminating lesions. The results suggest that BCNU, like platinum compounds, can induce lesions resulting in termination of transcription in vitro, although the predominant transcription-terminating lesions, unlike those produced by cis-diamminedichloroplatinum(II), most likely represent interstrand DNA cross-links.