Spatial patterns of climate change across the Paleocene-Eocene Thermal Maximum.

The Paleocene-Eocene Thermal Maximum (PETM; 56 Ma) is one of our best geological analogs for understanding climate dynamics in a "greenhouse" world. However, proxy data representing the event are only available from select marine and terrestrial sedimentary sequences that are unevenly distributed across Earth's surface, limiting our view of the spatial patterns of climate change. Here, we use paleoclimate data assimilation (DA) to combine climate model and proxy information and create a spatially complete reconstruction of the PETM and the climate state that precedes it ("PETM-DA"). Our data-constrained results support strong polar amplification, which in the absence of an extensive cryosphere, is related to temperature feedbacks and loss of seasonal snow on land. The response of the hydrological cycle to PETM warming consists of a narrowing of the Intertropical Convergence Zone, off-equatorial drying, and an intensification of seasonal monsoons and winter storm tracks. Many of these features are also seen in simulations of future climate change under increasing anthropogenic emissions. Since the PETM-DA yields a spatially complete estimate of surface air temperature, it yields a rigorous estimate of global mean temperature change (5.6 ∘C; 5.4 ∘C to 5.9 ∘C, 95% CI) that can be used to calculate equilibrium climate sensitivity (ECS). We find that PETM ECS was 6.5 ∘C (5.7 ∘C to 7.4 ∘C, 95% CI), which is much higher than the present-day range. This supports the view that climate sensitivity increases substantially when greenhouse gas concentrations are high.

Practical management of myelofibrosis with ruxolitinib.

Treatment for the majority of patients with myelofibrosis is primarily based on symptom control as curative allogeneic stem cell transplantation is typically offered only to younger patients, especially those with poor prognosis disease. Around 50% of patients with myelofibrosis have the JAK2(V617F) mutation, but almost all patients have aberrant activation of the JAK-STAT signalling pathway. Recent efforts have focussed on the clinical use of JAK2 inhibitors to treat myelofibrosis. In this article, we present our recommendations for the practical management of myelofibrosis with ruxolitinib, a selective inhibitor of both JAK1 and JAK2. Ruxolitinib can significantly improve the quality of life of patients with myelofibrosis. There is also increasing evidence of a positive impact on survival. Consistent with the physiological role of JAK signalling the major toxicity of ruxolitinib is cytopenia. Managing cytopenia is key to maximising the therapeutic benefit of ruxolitinib. Further research into the safety of ruxolitinib in patients with thrombocytopenia is warranted, as is its role in special subgroups of patients, such as those undergoing stem cell transplantation and those experiencing thrombosis as a major manifestation of myelofibrosis.

Swimming sea anemones of Puget Sound: swimming of Actinostola new species in response to Stomphia coccinea.

Swimming as a response of the sea anemone Actinostola new species can be elicited as a result of contact with the submarginal surface of another swimming sea anemone Stomphia coccinea. However, Stomphia does not swim as a result of contact with Actinostola. In all other known respects, swimming is caused in both species by the same stimuli, including certain starfishes, a nudibranch, and electrical stimuli. No agent that causes Actinostola to swim has been detected in extracts, rubbings, or dried matter from Stomphia.

Current and emerging tests for the laboratory monitoring of chronic myeloid leukaemia and related disorders.

Chronic myeloid leukaemia (CML) is a molecularly defined disease. The BCR-ABL fusion occurs in all cases of classical CML and leukaemic cells express a constitutively activated BCR-ABL tyrosine kinase. Other fusion oncogenes involving tyrosine kinases, including ABL and PDGFRA/B, have been identified, and are associated with leukaemic syndromes that may resemble CML. The discovery and treatment of these related disorders has been facilitated by our detailed understanding of CML. Imatinib mesylate has significantly improved the outcome of patients with CML, but there remains a significant minority of chronic phase CML patients for whom the response to treatment with standard dose imatinib is suboptimal. Cytogenetic and molecular monitoring of the response to treatment provides important prognostic information. Achievement of a major molecular response (MMR) in chronic phase patients treated de novo with imatinib confers near 100% freedom from progression to advanced phase, and MMR is now an important goal of therapy. Standardisation of BCR-ABL molecular monitoring is under way and should enable the accurate and reproducible identification of MMR in laboratories around the world. Point mutations in the kinase domain of BCR-ABL are the most common cause of acquired resistance to imatinib treatment. The susceptibility of a mutation to imatinib, nilotinib, or dasatinib may help to guide changes in therapy in a patient with resistance. In addition to these established methods of monitoring, there are new tests in development that may assist in determining prognosis and optimising therapy. Among patients receiving the same dose of imatinib, the plasma level of imatinib shows considerable inter-patient variation, and there is emerging evidence that higher levels may be associated with improved response to treatment. The intracellular concentration of imatinib also shows considerable variation, most likely related to differences in influx and efflux transport mechanisms. We discuss how these established and emerging assays might be used to optimise the treatment of CML patients.

Limited clinical value of regular bone marrow cytogenetic analysis in imatinib-treated chronic phase CML patients monitored by RQ-PCR for BCR-ABL.

Real-time quantitative polymerase chain reaction (PCR) for BCR-ABL mRNA in the peripheral blood (RQ-PCR) provides an accurate and reliable measure of response to therapy in chronic myeloid leukaemia (CML). We wanted to determine in what circumstances additional clinically relevant information was provided by simultaneous cytogenetic analysis in RQ-PCR monitored patients receiving imatinib treatment. We analysed 828 simultaneous RQ-PCR and bone marrow cytogenetic analyses from 183 patients with chronic phase CML with a median follow-up of 20 months. Cytogenetic progression was defined as Philadelphia (Ph)-positive clonal evolution, loss of complete cytogenetic response or an increase of > or = 20% Ph-positive cells. Cytogenetic progression occurred in 24/183 (13%) patients. At the time of cytogenetic progression, none of the 24 patients had a major molecular response (MMR; > or = 3-log reduction in BCR-ABL from standardised baseline). There were 320 RQ-PCR results from 95 patients indicating MMR. No abnormality was detected in any of the corresponding cytogenetic analyses. A policy of regular RQ-PCR monitoring with cytogenetic analysis targetted only to patients who have not achieved, or have lost MMR would represent a rational approach to monitoring and spare most patients the discomfort of multiple marrow aspirates. This approach depends upon availability of an accurate, reproducible RQ-PCR assay with ongoing quality assurance.

Treatment-free remission following frontline nilotinib in patients with chronic myeloid leukemia in chronic phase: results from the ENESTfreedom study.

The single-arm, phase 2 ENESTfreedom trial assessed the potential for treatment-free remission (TFR; i.e., the ability to maintain a molecular response after stopping therapy) following frontline nilotinib treatment. Patients with Philadelphia chromosome-positive chronic myeloid leukemia in chronic phase with MR4.5 (BCR-ABL1⩽0.0032% on the International Scale (BCR-ABL1IS)) and ⩾2 years of frontline nilotinib therapy were enrolled. Patients with sustained deep molecular response during the 1-year nilotinib consolidation phase were eligible to stop treatment and enter the TFR phase. Patients with loss of major molecular response (MMR; BCR-ABL1IS⩽0.1%) during the TFR phase reinitiated nilotinib. In total, 215 patients entered the consolidation phase, of whom 190 entered the TFR phase. The median duration of nilotinib before stopping treatment was 43.5 months. At 48 weeks after stopping nilotinib, 98 patients (51.6%; 95% confidence interval, 44.2-58.9%) remained in MMR or better (primary end point). Of the 86 patients who restarted nilotinib in the treatment reinitiation phase after loss of MMR, 98.8% and 88.4%, respectively, regained MMR and MR4.5 by the data cutoff date. Consistent with prior reports of imatinib-treated patients, musculoskeletal pain-related events were reported in 24.7% of patients in the TFR phase (consolidation phase, 16.3%).

A novel, somatic, transforming mutation in the extracellular domain of Epidermal Growth Factor Receptor identified in myeloproliferative neoplasm.

We describe a novel ERBB1/EGFR somatic mutation (p. C329R; c.985 T > C) identified in a patient with JAK2V617F Polycythaemia Vera (PV). This substitution affects a conserved cysteine residue in EGFR domain 2 and leads to the formation of a ligand-independent covalent receptor dimer, associated with increased transforming potential. Aberrant signalling from the EGFRC329R receptor is cell type-dependent and in the TF1.8 erythroid cell line expression of this mutant suppresses EPO-induced differentiation. Clonal analysis shows that the dominant JAK2V617F-positive clone in this PV patient harbors EGFRC329R, thus this mutation may contribute to clonal expansion. Somatic mutations affecting other ERBB and related receptor tyrosine kinases are observed in myeloproliferative neoplasms (MPN), and we show elevated EGFR levels in MPN samples, consistent with previous reports. Thus activation of this group of receptors, via multiple mechanisms, may contribute to clonal growth and survival of the JAK2V617F disease clone in MPN.

Corpus luteum deficiency as a cause of early recurrent abortion: a case history.

PIP: This paper presents a case history that suggests recurrent abortions in early pregnancy may be due to an inability to maintain an efficient corpus luteum. Pregnancy tests and the estimation of urinary human chorionic gonadotropin (HCG) titers were carried out for 62 days following the onset of the menstrual period preceding the study period. The patient was judged to have ovulated on the 19th or 20th day of the cycle and to have become pregnant at that point. The corpus luteum began to secrete progesterone in response to fertilization. Pregnanediol excretion rose from an average of 0.3 mg/day before ovulation to a high of 8.7 mg on day 31, but then fell sharply to only 1.0-3.0 mg/day, jeopardizing the chance of successful maintenance of the fetoplacental unit. HCG excretion was undetectable before day 43, then fluctuated between 1500-3500 IU/L, and became undetectable again on day 62. A heavy "menstrual" loss occurred on day 63. Progesterone replacement therapy in a subsequent pregnancy produced a successful outcome. This treatment should be administered as soon as the 1st period is missed. It is unclear whether corpus luteum dificiency is a direct cause of early recurrent abortion, or whether it is due to some others cause such as failure of the anterior pituitary to secrete sufficient luteinizing or luteotropic hormone.^ieng

Effect of ethanol on folate binding by isolated rat renal brush border membranes.

Deficiency of folic acid, an essential vitamin involved in critical metabolic pathways, occurs in several conditions, including alcoholism. In humans and animal models, chronic ethanol consumption leads to decreased plasma levels and increased urinary levels of folate. An isolated perfused rat kidney model has shown that ethanol produces increased urinary excretion of folate, suggesting a direct effect of ethanol on the kidney. Because the folate binding protein, located in the brush border membrane (BBM) of proximal tubule cells, is thought to be involved in renal folate reabsorption, the effects of ethanol on BBM binding of folate were assessed. Binding studies were conducted using isolated rat kidney cortex BBM preparations, incubated with 3H-labeled 5-methyltetrahydrofolate (5-CH3H4PteGlu) at varying concentrations (0.1-100 nM). Ethanol at 500 mg/dl did not significantly affect [3H]5-CH3H4PteGlu binding in BBM. The structural analogue, folic acid, decreased [3H]5-CH3H4PteGlu binding under similar conditions. Because of the lack of effect of ethanol on binding to isolated BBM, the effects of ethanol probably occur at other steps in the renal uptake and metabolism of folate.

Difference between nurses' and physicians' approach to denial in oncology.

A psychiatrist and a psychiatric nurse interviewed 33 physicians and 94 nurses at a cancer center about their experience working with oncology patients, including their usual approach to "denial" seen in these patients. Most respondents viewed denial as a useful, nearly universal defense mechanism, potentially capable of interfering with treatment. Physicians described a pattern in which their patients were presented with the facts one time during diagnosis and formulation of a treatment plan, after which denial was allowed and new facts not offered unless the denial was viewed as interfering with the medical intervention. Nurses more often referred to denial as a phase, stressing the importance of honesty in dealing with patients who are prone to deny. They experienced discomfort when patients who were suffering adverse effects of treatment seemed to need greater honesty from their physicians. Discussion of these differences includes the effect of the contexts in which nurses and physicians encounter denial as well as their complementary roles in patient care, and the differential goals and values of the two professions.

Relationships with patients in oncology: can a clinician be a friend?

Encounters with patients who are experiencing a life crisis such as cancer can be profoundly meaningful to both patients and those caring for them. Intense emotional involvement with patients can also lead to difficulties including "burnout" (Davitz and Davitz 1975), interstaff conflict (Burnham 1966; Pollack and Battle 1963; Robinson 1984; Weintraub 1964), and violation of professional boundaries (Applebaum 1990; Gartrell et al. 1986; Gutheil 1989a, 1989b). Nicholi (1988) has reviewed the challenges that psychotherapists face in maintaining relationships with patients that are both close and therapeutic. However, there has been little research into the relationships that clinicians in other medical disciplines have with their patients. This report describes both the stresses and rewards of relationships with oncology patients in a comprehensive sample of 192 staff members at a regional cancer center, interviewed about factors affecting their job satisfaction.

Human visual sensitivity to plumes with a Gaussian luminance distribution: experiments to develop an empirical probability of detection model.

This paper discusses results of a research project designed to develop an empirical model that could be used as a tool to predict human visual sensitivity to plumes. The resultant probability of detection algorithm (PROBDET) allows one to estimate the probability of a plume of known size, shape and contrast being detected visually. As a basis for the algorithm, a series of laboratory experiments using a high threshold signal detection procedure and computer generated images of plumes with Gaussian luminance distributions was conducted to measure human visual sensitivity to plumes. Results of the laboratory experiments are compared with results of contrast sensitivity experiments that examined visual sensitivity to stimuli with square and sine wave luminance distributions. An example of the PROBDET algorithm is presented to demonstrate its potential usefulness for assessing how probability of detection estimates change as plume size and contrast parameters vary. Since this research was designed to build on existing knowledge, a discussion of that knowledge and how it relates to the research conducted is also presented. The focus of this discussion is on the human visual system (HVS) and on how visual sensitivity is affected by factors such as the luminance of the stimulus and the surround, the luminance distribution of the stimulus, the size of the surround, and the size and spatial frequency characteristics of the stimulus.

Presenting a diagnosis of cancer: patients' views.

BACKGROUND: Although in general, patients in the United States are now told if they have been diagnosed as having cancer, little information is available either about the way in which this is done or about patients' satisfaction with how they are told. METHODS: Thirty-two patients were interviewed who had been given a diagnosis of cancer; one half were being treated at a comprehensive cancer center and one half at a community hospital. The study instrument, presented in a semistructured interview conducted by psychosocial clinicians, included specific questions about the setting and the manner in which the patients were told, their reactions to the diagnosis, and their suggestions of how physicians should inform others who have to be informed of a similar diagnosis. RESULTS: All patients were told of their diagnosis by a physician; 84% of the time the diagnosis was given in person. Patients said that being told with hope, information, and caring, and with respect for their privacy and wishes to have a supportive person present were particularly helpful. Almost 40% of patients reported at the time of the interview that their hopes were directed toward remission and optimal quality of life rather than toward a cure. Four of the six patients whose conditions had initially been misdiagnosed described subsequent mistrust of information received from physicians. CONCLUSIONS: These findings confirm the importance of a physician providing hope for and fostering trust in patients to whom they are presenting the diagnosis of cancer. The results indicate that physicians' help in providing treatment information contributes more to hope than does cheerfulness or optimism, and that patients who have been given a misdiagnosis require special consideration in order to reestablish trust.

Do we have to kill the last CML cell?

Previous experience in the treatment of chronic myeloid leukaemia (CML) has shown that the achievement of clinical, morphological and cytogenetic remission does not indicate eradication of the disease. A complete molecular response (CMR; no detectable BCR-ABL mRNA) represents a deeper level of response, but even CMR is not a guarantee of elimination of the leukaemia, because the significance of CMR is determined by the detection limit of the assay that is used. Two studies of imatinib cessation in CMR are underway, cumulatively involving over 100 patients. The current estimated rate of stable CMR after stopping imatinib is approximately 40%, but the duration of follow-up is relatively short. The factors that determine relapse risk are yet to be identified. The intrinsic capacity of any residual leukaemia [corrected] cells to proliferate following the withdrawal of treatment may be important, but there may also be a role for immunological suppression of the leukaemia [corrected] clone. No currently available test can formally prove that the leukaemic clone is eradicated. Here we discuss the sensitive measurement of minimal residual disease, and speculate on the biology of BCR-ABL-positive cells that may persist after effective therapy of CML.

Sensitive detection and quantification of minimal residual disease in chronic myeloid leukaemia using nested quantitative PCR for BCR-ABL DNA.

Increasing numbers of patients with chronic myeloid leukaemia (CML) treated with tyrosine kinase inhibitors achieve undetectable levels of BCR-ABL mRNA using sensitive quantitative real-time reverse transcriptase PCR (RT-qPCR) methods and a method to measure minimal residual disease (MRD) in patients with low levels could be of value. Following isolation and sequencing of the patient-specific BCR-ABL breakpoint, a DNA-based nested qPCR assay was established, and MRD was measured by this method and one-round RT-qPCR in 38 samples from 24 patients with CML. Mixing experiments using patient DNA in normal DNA indicated that DNA qPCR could detect BCR-ABL sequences at a limit of approximately 10⁻6. In 22 samples in which MRD was detectable by both methods, comparison of the results of DNA qPCR with the results obtained on the same sample by RT-qPCR showed good correlation. In another 16 samples, BCR-ABL mRNA was not detectable by RT-qPCR. In 8 of the 16 samples, BCR-ABL DNA was detected at levels ranging from 1.1 × 10⁻5 up to 2.8 × 10⁻4 and in the remaining eight samples BCR-ABL was not detected by either method. In one patient, who had stopped imatinib, an almost 1000-fold rise in MRD, to 5.2 × 10⁻4 was observed in sequential samples. Nested DNA qPCR was more sensitive than one-round RT-qPCR and could be used for the monitoring of patients with CML with very low levels of MRD.

Patients with chronic myeloid leukemia who maintain a complete molecular response after stopping imatinib treatment have evidence of persistent leukemia by DNA PCR.

Around 40-50% of patients with chronic myeloid leukemia (CML) who achieve a stable complete molecular response (CMR; undetectable breakpoint cluster region-Abelson leukemia gene human homolog 1 (BCR-ABL1) mRNA) on imatinib can stop therapy and remain in CMR, at least for several years. This raises the possibility that imatinib therapy may not need to be continued indefinitely in some CML patients. Two possible explanations for this observation are (1) CML has been eradicated or (2) residual leukemic cells fail to proliferate despite the absence of ongoing kinase inhibition. We used a highly sensitive patient-specific nested quantitative PCR to look for evidence of genomic BCR-ABL1 DNA in patients who sustained CMR after stopping imatinib therapy. Seven of eight patients who sustained CMR off therapy had BCR-ABL1 DNA detected at least once after stopping imatinib, but none has relapsed (follow-up 12-41 months). BCR-ABL1 DNA levels increased in all of the 10 patients who lost CMR soon after imatinib cessation, whereas serial testing of patients in sustained CMR showed a stable level of BCR-ABL1 DNA. This more sensitive assay for BCR-ABL1 provides evidence that even patients who maintain a CMR after stopping imatinib may harbor residual leukemia. A search for intrinsic or extrinsic (for example, immunological) causes for this drug-free leukemic suppression is now indicated.