Citations

On March 25 and 26, 2015, the National Heart, Lung, and Blood Institute sponsored a meeting on the State of the Science in Transfusion Medicine on the National Institutes of Health (NIH) campus in Bethesda, Maryland, which was attended by a diverse group of 330 registrants. The meeting's goal was to identify important research questions that could be answered in the next 5 to 10 years and which would have the potential to transform the clinical practice of transfusion medicine. These questions could be addressed by basic, translational, and/or clinical research studies and were focused on four areas: the three “classical” transfusion products (i.e., red blood cells, platelets, and plasma) and blood donor issues. Before the meeting, four working groups, one for each area, prepared five major questions for discussion along with a list of five to 10 additional questions for consideration. At the meeting itself, all of these questions, and others, were discussed in keynote lectures, small‐group breakout sessions, and large‐group sessions with open discourse involving all meeting attendees. In addition to the final lists of questions, provided herein, the meeting attendees identified multiple overarching, cross‐cutting themes that addressed issues common to all four areas; the latter are also provided. It is anticipated that addressing these scientific priorities, with careful attention to the overarching themes, will inform funding priorities developed by the NIH and provide a solid research platform for transforming the future practice of transfusion medicine.

The objective of the present study was to evaluate the influence of posture on the responses of blood pressure (BP) and heart rate (HR) to the Valsalva manoeuvre (VM). Neurohumoral activation, as well as changes in intravascular and intracardiac volumes and pressures, are well known effects of orthostatic stress. These changes are likely to have significant effects on cardiovascular reflexes, such as the response to the VM. However, the influence of posture on the VM has not been intensively evaluated, except for a few studies involving small sex- and age-selected case series. We therefore investigated the effects of posture on the VM in a larger non-selected group of healthy control subjects. In 19 healthy volunteers (ten female/nine male; age range 20–72 years, mean age 43 years), two reproducible VMs (40 mmHg; 15 s) were performed after 10 min of supine rest, 10 min of sitting and 10 min of standing. HR and BP were monitored continuously. End-diastolic volume, total peripheral resistance and cardiac output were calculated at baseline for each position. We found that assuming an upright position resulted in increases in total peripheral resistance and HR, accompanied by decreases in end-diastolic volume and cardiac output. The fall in BP during early phase II and the BP overshoot during phase IV were clearly more pronounced with increasing orthostatic stress, whereas the rise in BP during late phase II remained unchanged; pulse pressure was more compressed during phase II, but higher during phase IV. The Valsalva ratio was not significantly affected, but baroreflex gain (calculated from early phase II) was significantly decreased in the upright position. While a reduced late phase II was observed on one occasion in each of the lying and sitting positions, three abnormal responses were observed during standing. We conclude that posture has a significant influence on BP responses to the VM, probably resulting from changes in the intrathoracic blood volume. Standing results in a lower rate of ‘flat-top’ responses, but also seems to reduce the specificity of this test. Sympathetic activation in the upright position seems to blunt baroreflexes, leading to similar HR responses in spite of larger changes in BP.

Abstract Breast cancer is the most common invasive cancer in women worldwide and treatment related toxicity has high inter-patient variability. Our goal was to identify additional genetic predictors of toxicity by completing a pathway based analysis taking advantage of the genotyping results obtained through a GWAS of the same patients. For our analysis, we have utilized GWA data from the SUCCESS-A trial in which 3,754 breast cancer patients were treated with adjuvant chemotherapy. We have included SNPs associated with 112 genes involved in drug disposition and 375 genes in selected cancer pathways. We identified 35 SNPs associated with neutropenia (P-value <1×10−4). These patients initially received three cycles consisting of 5-fluorouracil (5-FU), cyclophosphamide, and epirubicin. Currently we are characterizing the function of three SNPs located within an intron of the hyaluronan mediated motility receptor (HMMR) gene that are associated with the neutropenia phenotype (P-value <1×10−4). These SNPs are highly associated with the expression of a gene encoding a B-cell survival factor, TNFSF13B, (P-value <1×10−5). Our in vitro studies using lymphoblastoid cell lines (LCLs) selected based on the genotypes of HMMR gene showed that heterozygous and homozygous variant cells (n = 6) have an increased sensitivity to 5-fluorouracil, but not cyclophosphamide or epirubicin when compared with homozygous wild-type cells (n = 6). LCLs exposed to the previously mentioned chemotherapeutic agents resulted in an upregulation of TNFSF13B gene expression and downregulation of HMMR gene expression. We have utilized a pathway based approach to analyzing GWA data to identify several SNPs in the HMMR gene highly associated with the expression of one of the top signals in the cytopenia GWAS. Our goal is to further characterize the role of HMMR gene variants in chemotherapy response by assessing whether combinations of these agents in vitro (including 5-FU) also have a genotype dependent response to cytotoxicity. Citation Format: Behzad Bidadi, Krishna R. Kalari, Matthias Rubner, Alexander Hein, Matthias W. Beckmann, Peter A. Fasching, Brigitte Rack, Wolfgang Janni, Richard Weinshilboum, Liewei Wang. Utilizing a pathway based analysis of genome wide association data to identify biomarkers of toxicity in breast cancer patients. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 5488. doi:10.1158/1538-7445.AM2015-5488

Abstract Next-generation sequencing is now commonly applied to measure genomic modifications, providing the opportunity for a more accurate view of cancer progression. That being said, several challenges including tumor purity, heterogeneity and the broad set of cancer associated cellular functions, increase the difficulty of interpreting cancer genomes and make analyzing them distinct from analysis of germline diseases. The ability to detect low allelic mutations in the broad set of cancer-associated genes is critically important. To address these issues, we developed an extended cancer panel, a targeted enrichment sequencing platform that includes over 1,300 cancer genes and 200 miRNAs that improves coverage in traditionally difficult to sequence NGS regions. In this study, we apply an integrated RNA/DNA analysis approach as well as our extended cancer panel to explore mutations in metastatic renal cell carcinoma (RCC) tissue samples before and after treatment. Our goal with this study was to test the importance of integrating DNA and RNA analysis, which allows for detection of mutational events that cannot be observed by either method alone. With RNA analysis it is possible to detect gene fusion events, expression of small variants (SNVs/indels), and gene expression levels while DNA analysis allows for detection of loss of heterozygosity (LOH), copy number variants (CNVs), and small variants. By integrating both the RNA and DNA analysis, it is possible to identify unique variant classes, such as unexpressed variants, allele specific expression (ASE), effects of CNVs on gene expression levels, and how fusion gene integration sites affect CNVs. In our study, each variant class was interpreted pre- and post-treatment, allowing for optimal analysis of treatment effectiveness. By applying both our RNA/DNA integration approach and our extended cancer panel to investigate metastatic RCC samples, we were able to classify many genomic alterations that drive cancer progression. For example, we found that anywhere from 5% to 30% of small variant mutations in driver genes called in the DNA reside in genes that are unexpressed in the RNA. Likewise, we noted multiple cases of ASE, where high profile variants observed in DNA were entirely absent in the RNA despite high expression levels. Strong correlations between CNVs observed in DNA and gene expression changes found in RNA were also detected. We also observed that about half of the RCC samples we tested were biallelic for VHL mutations, suggesting inherited predisposition combined with second hit somatic mutations, facilitating cancer progression. This analysis demonstrates how combining an integrated RNA/DNA approach with a cancer focused augmented enrichment panel allows for detection of both low allelic representation variants and unique variant classes, both of which are critical for accurate interpretation of cancer samples. Citation Format: Sean M. Boyle, Michael J. Clark, Elena Helman, Alexander S. Parker, Thai Ho, Shujun Luo, Scott Kirk, Parin Sripakdeevong, Mirian Karbelashvili, Deanna M. Church, Michael Snyder, John West, Rich Chen. Integrating RNA/DNA analysis with a comprehensive cancer panel to improve interpretations of stage four metastatic renal cell carcinoma. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 3899. doi:10.1158/1538-7445.AM2015-3899

Objectives: Female athletes are an at-risk population for anterior cruciate ligament (ACL) injury, with rates of injury significantly higher than the general population. Few studies have reported on a second ACL injury for female athletes. The purpose of this study was to (1) report the rate of subsequent ACL injury (ACL graft rupture or contralateral ACL tear) in competitive female soccer players, (2) compare these rates to those of other female athletes of similar competitive level, and (3) determine risk factors for second ACL injury in this athletic population. Methods: The medical record at our institution was reviewed for patients treated with primary ACL reconstruction between 1998 and 2013. Female patients injured during a competitive athletic event were included for further review, and followed for an average of 7.1 years postoperatively (range 1.0 - 17.7 years). Chi-square analysis was used to compare rate of graft rupture and contralateral ACL injury based on pre-operative Tegner score, graft type, and injury side for soccer players vs. other female athletes. Wilcoxon rank-sum test was used to compare rate of subsequent ACL injury to patient age. Results: 337 patients met our inclusion/exclusion criteria (90 soccer players; 247 non-soccer playing athletes) with a mean age of 24.0 years. Of the 337 athletes, 6 were injured during professional competition, 43 were injured during collegiate athletics, 184 during high school play, and 136 during recreational athletics. No patient demographical differences were found at baseline between the soccer group and non-soccer group, including Tegner scores. Overall, 21 soccer players (23.3%) sustained a second ACL injury compared to 21 (8.5%) non-soccer athletes (P < 0.001). Soccer players had significantly more graft ruptures (10.0% vs. 2.0%, P = 0.003) and more contralateral ACL tears (13.3% vs. 6.5%, P = 0.04). Risk factors for ACL graft tear included young age (mean 16.0 vs 24.3 years; P < 0.0001) and higher Tegner Activity Level scores (mean 8.1 vs. 7.4, P = 0.049), but were not risk factors for contralateral ACL injury. Graft selection and injury side showed no statistical significance on graft rupture or contralateral injury. Conclusion: Female soccer players treated with ACL reconstruction had an increased rate of second ACL injury, including graft tear and contralateral ACL injury, compared to a similar group of non-soccer female athletes (23.3% vs. 8.5%, P < 0.001). In addition, young age and higher activity level were risk factors for graft rupture in this population.

Objectives: Arthroscopic treatment for femoroacetabular impingement (FAI) generally has good results, but the outcome can worsen with increasing arthritis, largely defined as joint space narrowing. There remains a subset of hips with maintained joint space but with subchondral edema and cystic change of the acetabulum on MRI, with unknown outcome. Therefore, the purpose of this study was (1) to determine if postoperative outcome was worse for patients with subchondral edema on preoperative MRI compared to a matched control group and (2) to identify risk factors on MRI leading to inferior outcome. Methods: A review of patients who underwent arthroscopic hip surgery for FAI between 2007 and 2013 identified 530 patients. Of these, 39 patients had evidence of subchondral edema or subchondral cyst on the preoperative MRI with maintained joint space on preoperative radiographs. Lesions were characterized by grade, location and type using an established radiographic MRI classification system. A matched cohort of patients without evidence of subchondral edema or cyst was identified, and 2:1 matching was based on patient age, surgeon, surgery year within one year, surgical procedure, Tegner activity score, and Tonnis grade osteoarthritis changes on preoperative x-ray. Outcome was compared using the Hip Outcome Score and Modified Harris Hip Score between the two groups. Risk factors were then analyzed for type of lesion, grade and location of bone marrow lesion. Results: Thirty-nine patients (20 males, 19 females) showed preoperative MRI evidence of subchondral edema, and were followed for a mean of 23 months postoperatively (range, 12 - 60 months). Patients had an average age of 41 years (range, 19 - 67) and a preoperative Tegner score of 3.8 (range, 1 - 9). 87% of patients with subchondral cystic change had evidence of a grade IV full thickness cartilage lesion at the time of hip arthroscopy. Average Modified Harris Hip Scores were inferior for the subchondral group (79.9 ± 18.7) compared to the control group (86.6 ± 12.5; p = 0.027). In addition, Sport sub-scales of the Hip Outcome Score showed significantly lower scores for the subchondral group for both score (69.1 ± 27.0 vs. 79.5 ± 21.4, p = 0.018) and rating (66.7 ± 27.5 vs. 78.0 ± 20.8, p = 0.044). No radiographic risk factors, including type, location, or size of lesion were significant predictors of outcome. Two patients in the subchondral group were later converted to a total hip replacement. Conclusion: The presence of a subchondral acetabular cyst on MRI is indicative of a full thickness cartilage lesion at the time of arthroscopy. These patients have inferior outcomes for arthroscopic treatment of FAI compared to patients with similar age and activity level without MRI subchondral changes. Therefore, we recommend caution with consideration of hip arthroscopy in this patient subset.

Abstract Background: Genome-wide association studies (GWAS) have so far reported 12 loci associated with serous epithelial ovarian cancer (EOC) risk. We hypothesized that some of these loci function through nearby transcription factor (TF) genes and that putative target genes of these TFs as identified by coexpression may also be enriched for additional EOC risk associations. Methods: We selected TF genes within 1 Mb of the top signal at the 12 genome-wide significant risk loci. Mutual information, a form of correlation, was used to build networks of genes strongly coexpressed with each selected TF gene in the unified microarray dataset of 489 serous EOC tumors from The Cancer Genome Atlas. Genes represented in this dataset were subsequently ranked using a gene-level test based on results for germline SNPs from a serous EOC GWAS meta-analysis (2,196 cases/4,396 controls). Results: Gene set enrichment analysis identified six networks centered on TF genes (HOXB2, HOXB5, HOXB6, HOXB7 at 17q21.32 and HOXD1, HOXD3 at 2q31) that were significantly enriched for genes from the risk-associated end of the ranked list (P &lt; 0.05 and FDR &lt; 0.05). These results were replicated (P &lt; 0.05) using an independent association study (7,035 cases/21,693 controls). Genes underlying enrichment in the six networks were pooled into a combined network. Conclusion: We identified a HOX-centric network associated with serous EOC risk containing several genes with known or emerging roles in serous EOC development. Impact: Network analysis integrating large, context-specific datasets has the potential to offer mechanistic insights into cancer susceptibility and prioritize genes for experimental characterization. Cancer Epidemiol Biomarkers Prev; 24(10); 1574–84. ©2015 AACR.

Abstract Background & Aims Accumulating evidence indicates that micro RNA s play a role in a number of disease processes including the pathogenesis of liver fibrosis in hepatitis C infection. Our goal is to add to the accruing information regarding micro RNA deregulation in liver fibrosis to increase our understanding of the underlying mechanisms of pathology and progression. Methods We used next generation sequencing to profile all detectable micro RNA s in liver tissue and serum from patients with hepatitis C, stages F1–F4 of fibrosis. Results We found altered expression of several micro RNA s, in particular, miR‐182, miR199a‐5p, miR‐200a‐5p and miR‐183 were found to be significantly upregulated in tissue from liver biopsies of hepatitis C patients with advanced fibrosis, stage F3 and F4, when compared with liver biopsies from patients with early fibrosis, stages F1 and F2. We also found miR‐148‐5p, miR‐1260b, miR‐122‐3p and miR‐378i among the micro RNA s most significantly down‐regulated from early to advanced fibrosis of the liver. We also sequenced the serum micro RNA s; however, we were not able to detect significant changes in circulating micro RNA s associated with fibrosis stage after adjusting for multiple tests. Conclusions Adding measurements of tissue micro RNA s acquired during routine biopsies will continue to increase our knowledge of underlying mechanisms of fibrosis. Our goal is that these data, in combination with studies from other researchers and future long‐term studies, could be used to enhance the staging accuracy of liver biopsies and expand the surveillance of patients at increased risk for cancer and progression to advanced fibrosis.

Study Design: Evidence-based systematic review. Objectives: To define the optimal treatment of fractures involving the C2 body, including those with concomitant injuries, based upon a systematic review of the literature. Summary of Background Data: Axis body fractures have customarily been treated nonoperatively, but there are some injuries that may require operative intervention. High-quality literature is sparse and there are few class I or class II studies to guide treatment decisions. Materials and Methods: A literature search was conducted using PubMed (MEDLINE), Cochrane Central Register of Controlled Trials, and Scopus (EMBASE, MEDLINE, COMPENDEX). The quality of literature was rated according to a grading tool developed by the Center for Evidence-based Medicine. Operative and nonoperative treatment of axis body fractures were compared using fracture bony union as the primary outcome measure. As risk factors for nonunion were not consistently reported, cases were analyzed individually. Results: The literature search identified 62 studies, of which 10 were case reports which were excluded from the analysis. A total of 920 patients from 52 studies were included. The overall bony union rate for all axis body fractures was 91%. Although the majority of fractures were treated nonoperatively, there has been an increasing trend toward operative intervention for Benzel type III (transverse) axis body fractures. Nearly 76% of axis body fractures were classified as type III fractures, of which 88% united successfully. Nearly all Benzel type I and type II axis body fractures were successfully treated nonoperatively. The risk factors for nonunion included: a higher degree of subluxation, fracture displacement, comminution, concurrent injuries, delay in treatment, and older age. Conclusions: High rates for fracture union are reported in the literature for axis body fractures with nonoperative treatment. High-quality prospective studies are required to develop consensus as to which C2 body fractures require operative fixation.

Abstract Purpose: Chemotherapy resistance remains a major challenge in the treatment of ovarian cancer. We hypothesize that germline polymorphisms might be associated with clinical outcome. Experimental Design: We analyzed approximately 2.8 million genotyped and imputed SNPs from the iCOGS experiment for progression-free survival (PFS) and overall survival (OS) in 2,901 European epithelial ovarian cancer (EOC) patients who underwent first-line treatment of cytoreductive surgery and chemotherapy regardless of regimen, and in a subset of 1,098 patients treated with ≥4 cycles of paclitaxel and carboplatin at standard doses. We evaluated the top SNPs in 4,434 EOC patients, including patients from The Cancer Genome Atlas. In addition, we conducted pathway analysis of all intragenic SNPs and tested their association with PFS and OS using gene set enrichment analysis. Results: Five SNPs were significantly associated (P ≤ 1.0 × 10−5) with poorer outcomes in at least one of the four analyses, three of which, rs4910232 (11p15.3), rs2549714 (16q23), and rs6674079 (1q22), were located in long noncoding RNAs (lncRNAs) RP11-179A10.1, RP11-314O13.1, and RP11-284F21.8, respectively (P ≤ 7.1 × 10−6). ENCODE ChIP-seq data at 1q22 for normal ovary show evidence of histone modification around RP11-284F21.8, and rs6674079 is perfectly correlated with another SNP within the super-enhancer MEF2D, expression levels of which were reportedly associated with prognosis in another solid tumor. YAP1- and WWTR1 (TAZ)-stimulated gene expression and high-density lipoprotein (HDL)-mediated lipid transport pathways were associated with PFS and OS, respectively, in the cohort who had standard chemotherapy (pGSEA ≤6 × 10−3). Conclusions: We have identified SNPs in three lncRNAs that might be important targets for novel EOC therapies. Clin Cancer Res; 21(23); 5264–76. ©2015 AACR.