Search

PDF file - 26K, Simultaneous inhibition of mTOR and AKT pathways is synergistic in Breast cancer cell lines. A-B. Shown here are normalized isobolograms of treatment effects of Rapamycin and MK-2206, in the above cell lines. Proportion of MK-2206 IC50 is shown on the X-axis, and proportion of Rapamycin IC50 are shown on the Y-axis. Points at or near the red line are indicative of additive effects of the two agents; those below the line are indicative of synergistic effects.

Purpose: The mTOR pathway is constitutively activated in diffuse large B-cell lymphoma (DLBCL). mTOR inhibitors have activity in DLBCL, although response rates remain low. We evaluated DLBCL cell lines with differential resistance to the mTOR inhibitor rapamycin: (i) to identify gene expression profile(s) (GEP) associated with resistance to rapamycin, (ii) to understand mechanisms of rapamycin resistance, and (iii) to identify compounds likely to synergize with mTOR inhibitor.Experimental Design: We sought to identify a GEP of mTOR inhibitor resistance by stratification of eight DLBCL cell lines with respect to response to rapamycin. Then, using pathway analysis and connectivity mapping, we sought targets likely accounting for this resistance and compounds likely to overcome it. We then evaluated two compounds thus identified for their potential to synergize with rapamycin in DLBCL and confirmed mechanisms of activity with standard immunoassays.Results: We identified a GEP capable of reliably distinguishing rapamycin-resistant from rapamycin-sensitive DLBCL cell lines. Pathway analysis identified Akt as central to the differentially expressed gene network. Connectivity mapping identified compounds targeting Akt as having a high likelihood of reversing the GEP associated with mTOR inhibitor resistance. Nelfinavir and MK-2206, chosen for their Akt-inhibitory properties, yielded synergistic inhibition of cell viability in combination with rapamycin in DLBCL cell lines, and potently inhibited phosphorylation of Akt and downstream targets of activated mTOR.Conclusions: GEP identifies DLBCL subsets resistant to mTOR inhibitor therapy. Combined targeting of mTOR and Akt suppresses activation of key components of the Akt/mTOR pathway and results in synergistic cytotoxicity. These findings are readily adaptable to clinical trials. Clin Cancer Res; 18(9); 2534–44. ©2012 AACR.

PDF file - 24K, The cytotoxic agent Doxorubicin synergizes with Rapamycin, MK-2206 and their combination, in DLBCL cell lines. A-B. 106 cells/ml of two Rapamycin-sensitive cell lines (SUDHL-6 and WSU-NHL) and two Rapamycin-resistant cell lines (SUDHL-4 and OCI-Ly19) DLBCL cells were treated with single-agent Rapamycin, MK-2206, and Doxorubicin; the combination of Rapamycin and Doxorubicin; and the combination of MK-2206 and Doxorubicin, each for 48h. Viability was assessed by a fluorometric resazurin reduction assay. Each experiment was performed in octuplicate, and repeated once, with representative results shown. Shown here are normalized isobolograms of treatment effects of Rapamycin and Doxorubicin (A), and MK-2206 and Doxorubicin (B), in the Rapamycin-resistant cell line SUDHL-4. Proportion of Doxorubicin IC50 is shown on the X-axis, and proportion of Rapamycin IC50 and MK-2206 IC50, respectively, are shown on the Y-axes. Points at or near the red line are indicative of additive effects of the two agents; those below the line are indicative of synergistic effects. C. Rapamycin-resistant (SUDHL-4 and OCI-Ly19) and Rapamycin-sensitive (SUDHL-6 and WSU-NHL) were treated with the combination of three agents (Rapamycin, MK-2206, and Doxorubicin) for 48h as described above, and viability was assessed. Combination indices (CI) for the treatment effect were calculated using the Chou-Talalay equation (see Methods and Materials), and are shown here. CI Values below 0.8 indicate the presence of synergistic effect.

PDF file - 121K, A-C. The Rapamycin-resistant cell lines OCI-Ly19 (A) and SUDHL-4 (C) and the Rapamycin-sensitive cell line WSU-NHL (B) were treated for 3 hours and 6 hours with Rapamycin, Nelfinavir, and the combination of the two agents, after which cell lysates were prepared and analyzed by Western blot technique. Shown here are results using antibodies against phosphorylated Akt (p-Akt), phospho-S-6 ribosomal protein (p-S6RP), and phosphorylated 4-EBP-1 (p-4EBP-1).

PDF file - 24K, Vinblastine does not synergize with Rapamycin in SU-DHL 4 cell line. A-B. Approximately 106 cells/ml of SUDHL-4 and SUDHL-6 were treated with Rapamycin, Vinblastine, and the combination of both drugs (all doses lower than IC50 for each drug), for 48h. Viability was assessed by a fluorometric resazurin reduction assay. Each experiment was performed in octuplicate, and repeated twice. Shown here are representative results. C-D. Combination indices for the effects of combination of Rapamycin and Vinblastine on viability, as determined using the Chou-Talalay equation, are shown.

PDF file - 85K, A. Rapamycin-resistant cell line SUDHL-4 was treated for 6 hours with Rapamycin at 25 nM, MK-2206 at 300 nM, and the combination, after which cell lysates were prepared and analyzed by Western blot technique. Each experiment was repeated, with representative results provided. Shown here are results from analysis of cleaved caspase-3 and cleaved PARP. B-C. The Rapamycin-resistant cell line OCI-Ly19 (B) and the Rapamycin-sensitive cell line WSU-NHL (C) were treated for 3 and 6 hours with Rapamycin, MK-2206, and the combination, after which cell lysates were prepared and analyzed by Western blot technique. Shown here are results using antibodies against phosphorylated Akt (p-Akt), phospho-S-6 ribosomal protein (p-S6RP), and phosphorylated 4-EBP-1 (p-4EBP-1). Experiments were performed in duplicate, with representative results shown.

PDF file - 294K, A. Using the Core Analysis function on the Ingenuity Pathway Analysis (IPA) Server, a gene signature of only those genes over-expressed by Rapamycin-resistant cell lines (p

Background Little is known about the long-term health sequelae and outcomes of various organ failures in ICU survivors of Covid-19. The aim of our research was to study the characteristics of 120-day ICU survivors of the initial pandemic surge and report their long term (>6 months) outcomes. Methods We conducted a telephone questionnaire-based follow up study of 120- day survivors of Covid-19 admitted to ICUs at Montefiore Medical Center, Bronx, NY from 3/10/2020 to 4/11/2020. The study period was 2 months (11/1/2020-12/31/2020). Results 126 out of 300 (42%) survived to 120-days post-hospital discharge. The median age of survivors was 54 (47-61) years. Seventy-eight (62%) patients developed acute kidney injury (AKI); thirty-five (44.9%) of them required renal replacement therapy (RRT). One hundred-five (83.3%) required invasive mechanical ventilation; ten of them required tracheotomy. 103 (81.7%) completed the telephone questionnaire-based study, at a median (IQR) of 216.5 (200-234.5) days after hospital discharge. 29 (28.2%) patients reported persistent shortness of breath, 24, (23.3%) complained of persistent cough, and persistent anosmia in 9 (8.8%). AKI resolved completely in 58 (74.4%) patients. Of 35 AKI patients who required initiation of RRT during hospitalization, 27 (77%) were liberated from RRT and 20 (57%) had resolution of AKI. Of 20 patients without AKI resolution, 12 developed chronic kidney disease, whereas 8 still require RRT. Thirty-three (32.4%) patients developed post-traumatic stress disorder (PTSD) and 10 (11.8%) reported major depression. Many of the patients (68%) regained baseline functional status. Readmissions occurred in 22.3% patients within first 6 months after discharge. Conclusion Persistent symptoms of long Covid have been reported in ICU survivors of Covid-19 for extended durations. Outcomes of Covid-19 associated acute kidney injury are excellent. There is a high incidence of PTSD and depression in COVID-19 ICU survivors. Functional outcomes are good, but these patients remain at increased risk of hospital readmission.

Social determinants of health may significantly impact overall health and drive health disparities. We evaluated the association between social determinants of health and overactive bladder severity.We conducted a multicenter, cross-sectional study of patients presenting to outpatient female pelvic medicine and reconstructive surgery clinics at Montefiore Medical Center (Bronx, New York) and Johns Hopkins Bayview Medical Center (Baltimore, Maryland) from November 2018 to November 2019. Surveys were administered to screen for overactive bladder (Overactive Bladder-Validated 8-Question Screener) and to evaluate social determinants of health. Ordinal logistic regression models were used to examine the association between overactive bladder symptom level and social determinants of health items, while adjusting for age, race, body mass index, parity, history of pelvic surgery and clinical site.A total of 256 patients with a mean±SD age of 58.6±14.2 years and body mass index of 30.4±7.5 kg/mIn this cross-sectional study, certain social determinants of health were associated with greater overactive bladder severity. Unmet social needs may impact the success of overactive bladder treatment. Urologists should consider collaborating with social work and mental health specialists to better serve patients with overactive bladder and social determinants of health needs.

Introduction Behavioral-education interventions have the potential to improve quality of life and self-care for patients on hemodialysis (HD) but have not been incorporated into routine clinical practice. The purpose of this pilot study was to determine the feasibility of delivering a simple behavioral-education intervention using cognitive behavioral strategies in patients receiving HD with poor quality of life. Methods In this mixed methods study, HD patients were randomly assigned to the study intervention (8 behavioral-education sessions delivered over 12 weeks) or a control group of dialysis education alone. Kidney disease quality of life (KDQOL)-36 scores, depressive symptoms and self-care behaviors were measured at weeks 0, 8, and 16. Following study completion, participants, social workers, and physicians provided their perspectives about the intervention via qualitative interviews. Findings Forty-five participants were randomized. Due, in part, to social worker attrition from the intervention arm, 34 participants (76%) completed at least 1 study session and were included in the analysis. The intervention led to modest, but non-significant, increase in KDQOL-physical component summary scores (+3.1±1.2 points) from week 0 to week 16. There were small, non-significant decreases in interdialytic weight gain and pre-dialysis phosphorus levels in the intervention group. Participants felt that chair-side delivery was practical and efficient, and that content related to the impact of dialysis on daily life was unique and important. Suggestions for adapting the intervention included narrowing its content and its delivery by additional providers that are not necessarily therapy trained. Discussion In this pilot study, we were able to deliver a simple behavioral-education intervention to improve both quality of life and self-care. Participants had a positive impression of the intervention, but we did not find significant improvements in quality of life or self-care. We will now adapt our intervention by narrowing its content and by using other providers that are focused solely on delivering the intervention.

ObjectivesNearly 20% of pregnancies in patients with SLE result in an adverse pregnancy outcome (APO). We previously developed an APO prediction model using logistic regression and data from Predictors of pRegnancy Outcome: bioMarkers In Antiphospholipid Antibody Syndrome and Systemic Lupus Erythematosus (PROMISSE), a large multicentre study of pregnant women with mild/moderate SLE and/or antiphospholipid antibodies. Our goal was to determine whether machine learning (ML) approaches improve APO prediction and identify other risk factors.MethodsThe PROMISSE data included 41 predictors from 385 subjects; 18.4% had APO (preterm delivery due to placental insufficiency/pre-eclampsia, fetal/neonatal death, fetal growth restriction). Logistic regression with stepwise selection (LR-S), least absolute shrinkage and selection operator (LASSO), random forest (RF), neural network (NN), support vector machines (SVM-RBF), gradient boosting (GB) and SuperLearner (SL) were compared by cross-validated area under the ROC curve (AUC) and calibration.ResultsPreviously identified APO risk factors, antihypertensive medication use, low platelets, SLE disease activity and lupus anticoagulant (LAC), were confirmed as important with each algorithm. LASSO additionally revealed potential interactions between LAC and anticardiolipin IgG, among others. SL performed the best (AUC=0.78), but was statistically indistinguishable from LASSO, SVM-RBF and RF (AUC=0.77 for all). LR-S, NN and GB had worse AUC (0.71–0.74) and calibration scores.ConclusionsWe predicted APO with reasonable accuracy using variables routinely assessed prior to the 12th week of pregnancy. LASSO and some ML methods performed better than a standard logistic regression approach. Substantial improvement in APO prediction will likely be realised, not with increasingly complex algorithms but by the discovery of new biomarkers and APO risk factors.

Critically ill patients are at risk of developing stress cardiomyopathy (SC) but can be under-recognized.To describe a case series of patients with SC admitted to critical care units.We conducted a retrospective observational study at a tertiary care teaching hospital. All adult (≥ 18 years old) patients admitted to the critical care units with stress cardiomyopathy over 5 years were included.Of 24279 admissions to the critical care units [19139 to medical-surgical intensive care units (MSICUs) and 5140 in coronary care units (CCUs)], 109 patients with SC were identified. Sixty (55%) were admitted to the coronary care units (CCUs) and forty-nine (45%) to the medical-surgical units (MSICUs). The overall incidence of SC was 0.44%, incidence in CCU and MSICU was 1.16% and 0.25% respectively. Sixty-two (57%) had confirmed SC and underwent cardiac catheterization whereas 47 (43%) had clinical SC, and did not undergo cardiac catheterization. Forty-three (72%) patients in the CCUs were diagnosed with primary SC, whereas all (100%) patients in MSICUs developed secondary SC. Acute respiratory failure that required invasive mechanical ventilation and shock developed in twenty-nine (59%) MSICU patients. There were no statistically significant differences in intensive care unit (ICU) mortality, in-hospital mortality, use of inotropic or mechanical circulatory support based on type of unit or anatomical variant.Stress cardiomyopathy can be under-recognized in the critical care setting. Intensivists should have a high index of suspicion for SC in patients who develop sudden or worsening unexplained hemodynamic instability, arrhythmias or respiratory failure in ICU.

Objectives To characterize the association between the use of physiologic assessment (central venous pressure, pulmonary artery occlusion pressure, stroke volume variation, pulse pressure variation, passive leg raise test, and critical care ultrasound) with fluid and vasopressor administration 24 hours after shock onset and with in-hospital mortality. Design Multicenter prospective cohort study between September 2017 and February 2018. Settings Thirty-four hospitals in the United States and Jordan. Patients Consecutive adult patients requiring admission to the ICU with systolic blood pressure less than or equal to 90 mm Hg, mean arterial blood pressure less than or equal to 65 mm Hg, or need for vasopressor. Interventions None. Measurement and main results Of 1,639 patients enrolled, 39% had physiologic assessments. Use of physiologic assessment was not associated with cumulative fluid administered within 24 hours of shock onset, after accounting for baseline characteristics, etiology and location of shock, ICU types, Acute Physiology and Chronic Health Evaluation III, and hospital (beta coefficient, 0.04; 95% CI, -0.07 to 0.15). In multivariate analysis, the use of physiologic assessment was associated with a higher likelihood of vasopressor use (adjusted odds ratio, 1.98; 95% CI, 1.45-2.71) and higher 24-hour cumulative vasopressor dosing as norepinephrine equivalent (beta coefficient, 0.37; 95% CI, 0.19-0.55). The use of vasopressor was associated with increased odds of in-hospital mortality (adjusted odds ratio, 1.88; 95% CI, 1.27-2.78). In-hospital mortality was not associated with the use of physiologic assessment (adjusted odds ratio, 0.86; 95% CI, 0.63-1.18). Conclusions The use of physiologic assessment in the 24 hours after shock onset is associated with increased use of vasopressor but not with fluid administration.

Objective: To describe the current landscape of palliative care (PC) in nursing homes (NHs) in New York State (NYS). Measurements: A statewide survey was completed by 149 respondents who named 61 different NHs as their workplace. Questions were related to presence, type, and composition of PC programs; perceptions of PC; barriers to implementing PC; and qualifying medical conditions. Results: Hospice is less available than palliative or comfort care programs, with three-fourths of NYS NH responded providing a PC program. In general, medical directors and physicians were more similar in perspective about the role/impact of PC compared to nursing and others. There was general agreement about the positive impact and role of PC in the NH. Funding and staffing were recognized as barriers to implementing PC. Conclusion: There is growing penetration of PC programs in NH facilities in NYS, with good perception of the appropriate utilization of PC programs. Financial reimbursement and staffing are barriers to providing PC in the NH and need to be addressed by the health-care system.

A robust classification procedure is developed based on ensembles of classifiers, with each classifier constructed from a different set of predictors determined by a random partition of the entire set of predictors. The proposed methods combine the results of multiple classifiers to achieve a substantially improved prediction compared to the optimal single classifier. This approach is designed specifically for high-dimensional data sets for which a classifier is sought. By combining classifiers built from each subspace of the predictors, the proposed methods achieve a computational advantage in tackling the growing problem of dimensionality. For each subspace of the predictors, we build a classification tree or logistic regression tree. Our study shows, using four real data sets from different areas, that our methods perform consistently well compared to widely used classification methods. For unbalanced data, our approach maintains the balance between sensitivity and specificity more adequately than many other classification methods considered in this study.

To use the Gompertz function to estimate the age and the amount of myopia at stabilization and to evaluate associated factors in the Correction of Myopia Evaluation Trial (COMET) cohort, a large ethnically diverse group of myopic children.The COMET enrolled 469 ethnically diverse children aged 6 to younger than 12 years with spherical equivalent refraction between -1.25 and -4.50 diopters (D). Noncycloplegic refraction was measured semiannually for 4 years and annually thereafter. Right eye data were fit to individual Gompertz functions in participants with at least 6 years of follow-up and at least seven refraction measurements over 11 years. Function parameters were estimated using a nonlinear least squares procedure. Associated factors were evaluated using linear regression.In total, 426 participants (91%) had valid Gompertz curve fits. The mean (SD) age at myopia stabilization was 15.61 (4.17) years, and the mean (SD) amount of myopia at stabilization was -4.87 (2.01) D. Ethnicity (P0.0001) but not sex or the number of myopic parents was associated with the age at stabilization. Ethnicity (P = 0.02) and the number of myopic parents (P = 0.01) but not sex were associated with myopia magnitude at stabilization. At stabilization, African Americans were youngest (mean age, 13.82 years) and had the least myopia (mean, -4.36 D). Participants with two versus no myopic parents had approximately 1.00 D more myopia at stabilization. The age and the amount of myopia at stabilization were correlated (r = -0.60, P0.0001).The Gompertz function provides estimates of the age and the amount of myopia at stabilization in an ethnically diverse cohort. These findings should provide guidance on the time course of myopia and on decisions regarding the type and timing of interventions.

There is increasing interest in the role of epigenetic and transcriptional dysregulation in the pathogenesis of a range of human diseases, not just in the best-studied example of cancer. It is, however, quite difficult for an individual investigator to perform these studies, as they involve genome-wide molecular assays combined with sophisticated computational analytical approaches of very large datasets that may be generated from various resources and technologies. In 2008, the Albert Einstein College of Medicine in New York, USA established a Center for Epigenomics to facilitate the research programs of its investigators, providing shared resources for genome-wide assays and for data analysis. As a result, several avenues of research are now expanding, with cancer epigenomics being complemented by studies of the epigenomics of infectious disease and a neuroepigenomics program.

CMI responses, combined with quantification of CMV DNA (DNAemia), may identify transplantation recipients at risk for invasive disease. PBMC were collected in pediatric transplantation candidates at one, three, and six months post-transplant in 10 subjects (six renal, three cardiac, one stem cell) and at single time points in eight HC and 14 children greater than one yr post-transplant (LTTx). Cells were stimulated with anti-CD3mAb or CMV pp65 peptide pools and responses assessed by IFNG enzyme-linked immunosorbent spot assay and cytokine secretion. IFNG responses to anti-CD3mAb were significantly lower pretransplant relative to HC and were further decreased at one and three months post-transplant, but recovered to levels comparable to HC by six months. Responses to pp65 among CMV-seropositive recipients followed a similar pattern but recovered by three months. CMV-seropositive LTTx and HC showed a Th1 cytokine response to pp65 stimulation. Three LTTx subjects developed CMV DNAemia; two demonstrated decreased responses to anti-CD3mAB (and pp65 in the CMV seropositive subject) at the onset of DNAemia, which recovered as DNAemia resolved. Monitoring CMI in children is feasible and may provide an adjunct biomarker to predict CMV progression and recovery.

Epigenetics is the study of heritable change other than those encoded in DNA sequence. Cytosine methylation of DNA at CpG dinucleotides is the most well-studied epigenetic phenomenon, although epigenetic changes also encompass non-DNA methylation mechanisms, such as covalent histone modifications, micro-RNA interactions, and chromatin remodeling complexes. Methylation changes, both global and gene specific, have been observed to be associated with disease, particularly in cancer.This chapter begins with a general overview of epigenomics, and then focuses on understanding and analyzing genome-wide cytosine methylation data. There are many microarray-based techniques available to measure cytosine methylation across the genome, as well as gold-standard techniques based on sequencing bisulfite converted DNA, which is used to measure methylation in a smaller, more targeted set of loci. We have provided an overview of many of the current technologies - their advantages, limitations, and recent improvements. Regardless of which technology is used, the goal is to produce a set of methylation measurements that are highly consistent with true methylation levels of the corresponding set of CpG dinucleotides.Identifying all loci with aberrant methylation or hypomethylation in disease, or in natural processes such as aging, requires the comparison of methylation levels across many samples. In such studies, the development of methylation-based diagnostic tools may be of interest, potentially to be used as early disease detection strategies based on a set of sentinel loci. In addition, the identification of loci with potentially reversible methylation events may result in new therapeutic options. Given the vast number of measurable sites, prioritization of candidate loci is an important and complex issue and rests on a foundation of appropriate statistical testing and summarization. Coupled with statistical estimates of importance, the genomic context of each locus measured may offer important information about the mechanisms by which epigenetic changes impact disease and allows us further refinement of candidate loci. We will conclude this chapter by identifying issues in building methylation-based models for prediction and potential directions of further statistical research in epigenetics.