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Natural killer (NK) cells are innate lymphocytes that possess traits of adaptive immunity, such as memory formation. However, the molecular mechanisms by which NK cells persist to form memory cells are not well understood. Using single-cell RNA sequencing, we identified two distinct effector NK cell (NKeff) populations following mouse cytomegalovirus infection. Ly6C–memory precursor (MP) NK cells showed enhanced survival during the contraction phase in a Bcl2-dependent manner, and differentiated into Ly6C+memory NK cells. MP NK cells exhibited distinct transcriptional and epigenetic signatures compared with Ly6C+NKeffcells, with a core epigenetic signature shared with MP CD8+T cells enriched in ETS1 and Fli1 DNA-binding motifs. Fli1 was induced by STAT5 signaling ex vivo, and increased levels of the pro-apoptotic factor Bim in early effector NK cells following viral infection. These results suggest that a NK cell-intrinsic checkpoint controlled by the transcription factor Fli1 limits MP NK formation by regulating early effector NK cell fitness during viral infection.

Context: Diclofenac is commonly used as pain relief. Hypoglycemia has rarely been reported due to aspirin and indomethacin use but not of any other nonsteroidal anti-inflammatory drugs. Case report: A 69-years old endocrinologist participated as a control in a glucagon-like peptide-1 (GLP-1) study. He decreased his plasma glucose to 1.8 mmol/L and developed full-blown hypoglycemic symptoms during an oral glucose tolerance test (OGTT). He had taken a 50 mg diclofenac tablet at 10 pm the evening before for a harmless muscle stretch in the lower back. Apart from well-controlled hypothyroidism he was healthy. During medical school he often had reactive hypoglycemia which came after intake of a carbohydrate rich but otherwise poor breakfast followed by bicycling. However, he had never experienced problems later in life after more decent meals containing slower absorbable carbohydrates. A 3-day continuous glucose monitoring (CGM) was performed three weeks after the OGTT test. A glucose value of 3.1 mmol/L was registered on the third CGM day in the afternoon after intake of 500 mg aspirin in the early morning the same day. Otherwise, all values were normal. A second OGGT where no medications apart from levothyroxine had been taken during at least a 2-week period adjacent was normal. Detailed analyses of the OGTTs showed that the GLP-1 levels before the test were higher after diclofenac exposure while the insulin levels increased after the glucose challenge which suggesting uncoupling. Conclusion: With this case report we would like to draw attention to that diclofenac may cause hypoglycemia.

Glioblastomas (GBMs) exhibit altered metabolism to support a variety of bioenergetic and biosynthetic demands for tumor growth, invasion, and drug resistance. Changes in glycolytic flux, oxidative phosphorylation, the pentose phosphate pathway, fatty acid biosynthesis and oxidation, and nucleic acid biosynthesis are observed in GBMs to help drive tumorigenesis. Both the genetic landscape of GBMs and the unique brain tumor microenvironment shape metabolism; therefore, an understanding of how both intrinsic and extrinsic factors modulate metabolism is becoming increasingly important for finding effect targets and therapeutics for GBM.

Purpose: Several studies have reported an association between hyponatremia and lethality. However, it remains elusive whether hyponatremia independently contributes to lethality. The aim of the study was to investigate associations between hyponatremia and lethality and differences in lethality between men and women hospitalized due to hyponatremia. Methods: Four registries were utilized in this population-based retrospective study: The National Patient Registry, the Cause of Death Register, the Swedish Prescribed Drug Register and the Total Population Register (NPR) from which the controls were sampled. All hospitalized patients with a first-ever principal ICD10 diagnosis of hyponatremia or syndrome of inappropriate ADH secretion in the NPR between 1 October 2005 and 31 December 2014 were defined as cases. Cox regression with adjustment for potential confounders was used. Results: 14,359 individuals with a principal diagnosis of hyponatremia, and 57,382 matched controls were identified. Median age was 76 years and the majority were women (72%). Median age for women and men was 79 and 68 years, respectively. Adjusted hazard ratios (and 95% CI) for lethality in those with hyponatremia compared with controls were for the entire population 5.5 (4.4–7.0) and in the subgroup free from previously known underlying disease 6.7 (3.3–13.3). Lethality in women with hyponatremia was lower compared with men: HR: 0.56 (0.49–0.64). In the healthier group the lethality remained lower for women: HR: 0.49 (0.34–0.71). Conclusions: Patients hospitalized due to hyponatremia faced an increased subsequent lethality that was independent of concomitant disease. This increase was nearly twice as large among men compared with women.

The objective of this study was to describe healthcare resource use and cost development in Sweden during 2006–2014 in a type 2 diabetes (T2D) population receiving glucose-lowering drugs (GLDs). In- and outpatient healthcare resource use and costs were extracted from mandatory national registries: the Cause of Death Register; the National Patient Register; and the Prescribed Drug Register. Primary care data were estimated based on an observational study including patients from 84 primary care centers in Sweden. Numbers of any cause inpatient, outpatient, and primary care contacts were extracted and direct healthcare costs were estimated. During 2006–2014, the number of inpatient and primary care contacts increased by approximately 70% (from 45,559 to 78,245 and from 4.9 to 8.8 million, respectively) and outpatient care contacts almost doubled (from 105,653 to 209,417). Mean annual per patient costs increased by 13%, reaching €4594. Total healthcare costs increased from €835 million to €1.684 billion. Inpatient care costs constituted 47% of total costs in 2014 (€783 million), primary care accounted for 24% (€405 million), outpatient care 18% (€303 million), non-GLD medications 6% (€109 million), and GLDs 5% (€84 million). Cardiovascular diseases (CVDs) were the most costly disease group in inpatient care (26%), whereas managing unspecified factors influencing health and T2D-associated diseases were the most costly in outpatient care (16 and 11%, respectively). The healthcare costs of the GLD-treated T2D population doubled during 2006–2014, mostly driven by the increasing size of this population, of which inpatient care accounted for 47%. GLDs constituted the smallest share of costs. CVD was the most resource-requiring disease group.

Cross-talk among oncogenic signaling and metabolic pathways may create opportunities for new therapeutic strategies in cancer. Here we show that although acute inhibition of EGFR-driven glucose metabolism induces only minimal cell death, it lowers the apoptotic threshold in a subset of patient-derived glioblastoma (GBM) cells. Mechanistic studies revealed that after attenuated glucose consumption, Bcl-xL blocks cytoplasmic p53 from triggering intrinsic apoptosis. Consequently, targeting of EGFR-driven glucose metabolism in combination with pharmacological stabilization of p53 with the brain-penetrant small molecule idasanutlin resulted in synthetic lethality in orthotopic glioblastoma xenograft models. Notably, neither the degree of EGFR-signaling inhibition nor genetic analysis of EGFR was sufficient to predict sensitivity to this therapeutic combination. However, detection of rapid inhibitory effects on [18F]fluorodeoxyglucose uptake, assessed through noninvasive positron emission tomography, was an effective predictive biomarker of response in vivo. Together, these studies identify a crucial link among oncogene signaling, glucose metabolism, and cytoplasmic p53, which may potentially be exploited for combination therapy in GBM and possibly other malignancies.

In patients with type 2 diabetes and a high cardiovascular risk profile, the sodium-glucose co-transporter-2 (SGLT2) inhibitors empagliflozin and canagliflozin have been shown to lower cardiovascular morbidity and mortality. Using real-world data from clinical practice, we aimed to compare cardiovascular mortality and morbidity in new users of SGLT2 inhibitors versus new users of other glucose-lowering drugs, in a population with a broad cardiovascular risk profile.

Human cells have twenty-three pairs of chromosomes. In cancer, however, genes can be amplified in chromosomes or in circular extrachromosomal DNA (ecDNA), although the frequency and functional importance of ecDNA are not understood. We performed whole-genome sequencing, structural modelling and cytogenetic analyses of 17 different cancer types, including analysis of the structure and function of chromosomes during metaphase of 2,572 dividing cells, and developed a software package called ECdetect to conduct unbiased, integrated ecDNA detection and analysis. Here we show that ecDNA was found in nearly half of human cancers; its frequency varied by tumour type, but it was almost never found in normal cells. Driver oncogenes were amplified most commonly in ecDNA, thereby increasing transcript level. Mathematical modelling predicted that ecDNA amplification would increase oncogene copy number and intratumoural heterogeneity more effectively than chromosomal amplification. We validated these predictions by quantitative analyses of cancer samples. The results presented here suggest that ecDNA contributes to accelerated evolution in cancer.

The most common positron emission tomography (PET) radio-labeled probe for molecular diagnostics in patient care and research is the glucose analog, 2-deoxy-2-[F-18]fluoro-D-glucose (18F-FDG). We report on an integrated microfluidics-chip/beta particle imaging system for in vitro18F-FDG radioassays of glycolysis with single cell resolution. We investigated the kinetic responses of single glioblastoma cancer cells to targeted inhibitors of receptor tyrosine kinase signaling. Further, we find a weak positive correlation between cell size and rate of glycolysis.

Ribosomal biogenesis involves the processing of pre-ribosomal RNA. A deficiency of some ribosomal proteins (RPs) impairs processing and causes Diamond Blackfan anemia (DBA), which is associated with anemia, congenital malformations and cancer. p53 mediates many features of DBA, but the mechanism of p53 activation remains unclear. Another hallmark of DBA is the upregulation of adenosine deaminase (ADA), indicating changes in nucleotide metabolism. In RP-deficient zebrafish, we found activation of both nucleotide catabolism and biosynthesis, which is consistent with the need to break and replace the faulty ribosomal RNA. We also found upregulation of deoxynucleotide triphosphate (dNTP) synthesis – a typical response to replication stress and DNA damage. Both RP-deficient zebrafish and human hematopoietic cells showed activation of the ATR/ATM-CHK1/CHK2/p53 pathway. Other features of RP deficiency included an imbalanced dNTP pool, ATP depletion and AMPK activation. Replication stress and DNA damage in cultured cells in non-DBA models can be decreased by exogenous nucleosides. Therefore, we treated RP-deficient zebrafish embryos with exogenous nucleosides and observed decreased activation of p53 and AMPK, reduced apoptosis, and rescue of hematopoiesis. Our data suggest that the DNA damage response contributes to p53 activation in cellular and zebrafish models of DBA. Furthermore, the rescue of RP-deficient zebrafish with exogenous nucleosides suggests that nucleoside supplements could be beneficial in the treatment of DBA.

Pharmacological targeting of metabolic processes in cancer must overcome redundancy in biosynthetic pathways. Deoxycytidine (dC) triphosphate (dCTP) can be produced both by the de novo pathway (DNP) and by the nucleoside salvage pathway (NSP). However, the role of the NSP in dCTP production and DNA synthesis in cancer cells is currently not well understood. We show that acute lymphoblastic leukemia (ALL) cells avoid lethal replication stress after thymidine (dT)-induced inhibition of DNP dCTP synthesis by switching to NSP-mediated dCTP production. The metabolic switch in dCTP production triggered by DNP inhibition is accompanied by NSP up-regulation and can be prevented using DI-39, a new high-affinity small-molecule inhibitor of the NSP rate-limiting enzyme dC kinase (dCK). Positron emission tomography (PET) imaging was useful for following both the duration and degree of dCK inhibition by DI-39 treatment in vivo, thus providing a companion pharmacodynamic biomarker. Pharmacological co-targeting of the DNP with dT and the NSP with DI-39 was efficacious against ALL models in mice, without detectable host toxicity. These findings advance our understanding of nucleotide metabolism in leukemic cells, and identify dCTP biosynthesis as a potential new therapeutic target for metabolic interventions in ALL and possibly other hematological malignancies.

Nucleotide deficiency causes replication stress (RS) and DNA damage in dividing cells. How nucleotide metabolism is regulated in vivo to prevent these deleterious effects remains unknown. In this study, we investigate a functional link between nucleotide deficiency, RS, and the nucleoside salvage pathway (NSP) enzymes deoxycytidine kinase (dCK) and thymidine kinase (TK1). We show that inactivation of dCK in mice depletes deoxycytidine triphosphate (dCTP) pools and induces RS, early S-phase arrest, and DNA damage in erythroid, B lymphoid, and T lymphoid lineages. TK1−/− erythroid and B lymphoid lineages also experience nucleotide deficiency but, unlike their dCK−/− counterparts, they still sustain DNA replication. Intriguingly, dCTP pool depletion, RS, and hematopoietic defects induced by dCK inactivation are almost completely reversed in a newly generated dCK/TK1 double-knockout (DKO) mouse model. Using NSP-deficient DKO hematopoietic cells, we identify a previously unrecognized biological activity of endogenous thymidine as a strong inducer of RS in vivo through TK1-mediated dCTP pool depletion. We propose a model that explains how TK1 and dCK “tune” dCTP pools to both trigger and resolve RS in vivo. This new model may be exploited therapeutically to induce synthetic sickness/lethality in hematological malignancies, and possibly in other cancers.

The economics of breast cancer recurrence are poorly understood. For this retrospective cohort study, the authors evaluated the economic burden of breast cancer recurrence by using data from a large Midwestern healthcare system.Women with Stage I or II breast cancer (according to the American Joint Commission on Cancer staging criteria) were identified from the tumor registry of the Henry Ford Health System. The economic burden of breast cancer recurrence was estimated from patient charges (adjusted to 2003 U.S. dollars).From 1996 to 2002, 1616 patients with early breast cancer were identified, including 192 patients who had recurrent tumors. Patients with recurrence had significantly greater charges in the 6‐month and 12‐month postrecurrence periods ($45,855 and $79,253, respectively) compared with the 6‐month and 12‐month prerecurrence periods ($10,715 and $12,344, respectively; both P <.001). This was evident for all recurrence types (locoregional, contralateral breast, and distant), but it was most evident for distant recurrences. In a regression analysis that was adjusted for baseline characteristics, the mean monthly charges were significantly greater for patients with recurrence versus patients without recurrence (P <.001), and this was true for each recurrence type. For women with recurrence (n = 74 patients), the mean charges during the 6‐month postrecurrence period were significantly greater than mean charges during the initial 6‐month period after diagnosis ($50,355 vs. $38,254; P <.01). Quarterly charges for continuing care postrecurrence were significantly greater than prerecurrence charges ($4934 vs. $1825; P <.001). The mean charges for terminal care were significantly greater (P <.01) for women with recurrence (n = 27 patients, $63,434) versus women without recurrence (n = 65 patients, $53,872).Patients with early breast cancer who experienced recurrence required more costly care than patients who did not develop recurrent disease. Therapies that reduce the risk of recurrence may reduce costs significantly. Cancer 2006. © 2006 American Cancer Society.

Many consensus guidelines recommend routine surveillance to detect recurrent disease among cancer survivors. We compare surveillance care receipt to guideline recommendations.

The article focuses on the Maritime Prepositioning Force (MPF) Operations in Regimental Combat Team (RCT-7) of the U.S. Operation Iraqi Freedom was a logistical success as much as it was an operational success. The logisticians of RCT-7, who supported the complex scheme of maneuver, used innovative and creative methods to support the rapid movement from the line of departure to Baghdad. The techniques and methods employed were the result of a 2-year training cycle in which the logisticians participated. The foundation for this success was based on the employment of the MPF equipment that RCT-7 received during the arrival and assembly phase of the operation.

AbstractOrienting nonverbal responses and verbal responses of eight children with mental disabilities interacting in water with dolphins and in water with favorite toys away from dolphins were recorded and analyzed on videotape. Significant improvements in hierarchical cognitive responses occurred when interaction with dolphins was used as reinforcement compared with improvements made when the reinforcement used was a favorite toy. Water work with dolphins evoked a greater number of and higher level responses than without dolphins.

ABSTRACTLong-term effectiveness of dolphin assisted therapy, as practiced by Dolphin Human Therapy, was analyzed via a 15 item closed form, ratio scale parent questionnaire (n=71). Children with severe disabilities of many etiologies, from eight countries, received either one or two weeks of therapy in the multidisciplinary, behavior modification program. Results on three clinical issues were analyzed. First, children maintained or improved skills acquired in therapy about 50% of the time even after 12 months away from therapy. Second, no difference in long-term effects occurred as a function of differences in three categories (genetic, brain damage, unknown causes) of etiology (ANOVA, F(2,39)=2.79, p>0.05). Third, two weeks of therapy produced significantly better long-term results than did one week of therapy (t=3.105, df=28, p<0.01).

ABSTRACTThe effectiveness of two week dolphin-assisted therapy was compared to the effectiveness of six month conventional physical and speech-language therapy. Data were analyzed using a multiple baseline single subject across settings design, for 47 children with severe disabilities (20 females, 27 males), of multiple etiologies. Children were placed in a physical therapy group (n = 17, mean age = 6 years, 8 months) and a speech language group (n = 30, mean age = 6 years 5 months). Standardized charting procedures were used to measure acquisition of independent motor and speech-language skills. Use of t tests for nonindependent samples indicates that relative to conventional long-term therapy, dolphin-assisted therapy, as practiced by Dolphin Human Therapy, achieves positive results more quickly and is also more cost effective.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

The understanding of second‐line use of glucose‐lowering drugs (GLDs) in the general population with type 2 diabetes (T2D) treatment is important as recent results have shown cardiovascular benefits with sodium‐glucose cotransporter‐2 inhibitors (SGLT‐2i) and glucagon‐like peptide‐1 receptor agonists (GLP‐1RA). Our aim was to describe second‐line GLDtreatment patterns in four Nordic countries. All T2D patients treated with GLDbetween 2006 and 2015 were identified in prescribed drug registries in Denmark, Finland, Norway and Sweden, and linked with National Patient and Cause of Death Registries. Second‐line treatment was defined as a prescription of a second GLDclass following ≥6 months of metformin monotherapy. Index was the date of first dispense of the second‐line drug. A rapid uptake of newer GLDs (GLP‐1RA,DPP‐4i and SGLT‐2i) over the 10‐year observation period was seen in Denmark, Finland and Norway, while slower in Sweden. In 2015, 33,880 (3.1%) of 1,078,692 T2D patients initiated second‐line treatment, and newer GLDs were more commonly used in Finland (92%), Norway (71%) and Denmark (70%) vs Sweden (44%). In 2015, the use of older GLDs (insulin and sulphonylureas) was 7‐fold greater in Sweden compared to Finland (49% vs 7%), and 1.6‐fold greater compared with Denmark and Norway (49% vs 30% and 29%, respectively). Despite comparable demography and healthcare systems in four neighbouring countries, surprisingly large differences in second‐line use of newer GLDs were found. With recent evidence of potential cardiovascular benefits with newer GLDs, such differences may have an important impact on cardiovascular outcomes. This multinational study shows large differences in the uptake of newer second‐line glucose‐lowering drugs between four neighbouring and similar countries. In the light of recent paradigm shifting trial results for type 2 diabetes drug treatment, these large differences in modern management of type 2 diabetes are important to understand when planning updated guidelines and future health care.

No relevant conflicts of interest to declare.

Diamond-Blackfan Anemia (DBA) is a rare childhood bone marrow failure disorder, characterized by the presence of red cell aplasia, congenital abnormalities, and increased levels of adenosine deaminase (ADA). Haploinsufficiency of ribosomal proteins (RPs) due to mutations in RPS19 and RPL11 occurs approximately 25% and 5% of DBA patients, respectively. The pathogenesis of DBA has been associated with activation of p53, but the mechanism of how this leads to the erythroid defect in DBA patients is not well understood.