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Abstract Multiple myeloma (MM) develops from well-defined precursor stages; however, invasive bone marrow (BM) biopsy limits screening and monitoring strategies for patients. We enumerated circulating tumor cells (CTC) from 261 patients (84 monoclonal gammopathy of undetermined significance, 155 smoldering multiple myeloma, and 22 MM), with neoplastic cells detected in 84%. We developed a novel approach, MinimuMM-seq, which enables the detection of translocations and copy-number abnormalities through whole-genome sequencing of highly pure CTCs. Application to CTCs in a cohort of 51 patients, 24 with paired BM, was able to detect 100% of clinically reported BM biopsy events and could replace molecular cytogenetics for diagnostic yield and risk classification. Longitudinal sampling of CTCs in 8 patients revealed major clones could be tracked in the blood, with clonal evolution and shifting dynamics of subclones over time. Our findings provide proof of concept that CTC detection and genomic profiling could be used clinically for monitoring and managing disease in MM. Significance: In this study, we established an approach enabling the enumeration and sequencing of CTCs to replace standard molecular cytogenetics. CTCs harbored the same pathognomonic MM abnormalities as BM plasma cells. Longitudinal sampling of serial CTCs was able to track clonal dynamics over time and detect the emergence of high-risk genetic subclones.

Supplementary data contains additional Materials and Methods used to generate results presented only in the supplementary figures and tables, as well as more detailed bioinformatics methods. Figure S1 shows correlation between clinical measures of disease pathology, survival, and circulating tumor cells enumeration. Figure S2 shows characteristics of isolated circulating tumor cells from peripheral blood of precursor disease patients. Figure S3 shows cohort-level genomic characterization of tumor in MM precursor stages with CTCs. Figure S4 shows longitudinal and tissue-matched genomic characterization of driver mutations. Figure S5 shows comparison of mutational processes between BMPCs and CTCs assigned to most likely PCAWG composite reference signature. Table S1 shows clinical characteristics and sampling of participants in this study. Table S2 shows whole-genome sequencing coverage and library metrics. Table S3 shows clinical BM FISH results and cells recovered for cohort with matched samples. Table S4 shows comparison of BCR sequence between BMPCs and CTCs. Table S5 shows clinical BM FISH results of peripheral blood only cohort and CTCs recovered. Table S6 shows enumeration of single nucleotide variants and short insertions and deletions discovered from WGS of CTCs. Table S7 shows enumeration of structural variants reconstructed from WGS of CTCs.

Multiple myeloma (MM) develops from well-defined precursor stages; however, invasive bone marrow (BM) biopsy limits screening and monitoring strategies for patients. We enumerated circulating tumor cells (CTC) from 261 patients (84 monoclonal gammopathy of undetermined significance, 155 smoldering multiple myeloma, and 22 MM), with neoplastic cells detected in 84%. We developed a novel approach, MinimuMM-seq, which enables the detection of translocations and copy-number abnormalities through whole-genome sequencing of highly pure CTCs. Application to CTCs in a cohort of 51 patients, 24 with paired BM, was able to detect 100% of clinically reported BM biopsy events and could replace molecular cytogenetics for diagnostic yield and risk classification. Longitudinal sampling of CTCs in 8 patients revealed major clones could be tracked in the blood, with clonal evolution and shifting dynamics of subclones over time. Our findings provide proof of concept that CTC detection and genomic profiling could be used clinically for monitoring and managing disease in MM.Significance:In this study, we established an approach enabling the enumeration and sequencing of CTCs to replace standard molecular cytogenetics. CTCs harbored the same pathognomonic MM abnormalities as BM plasma cells. Longitudinal sampling of serial CTCs was able to track clonal dynamics over time and detect the emergence of high-risk genetic subclones.This article is highlighted in the In This Issue feature, p. 247

Introduction: Sixty million Latinxs make up 26.4% of all COVID-19 cases in the United States. It is uncertain whether behaviors and beliefs of immunizations among Latinxs is influenced by social determinants of health. The purpose of this study was to examine how social determinants of health predict COVID-19 behaviors and beliefs toward immunization among Latinxs. Methods: In this exploratory study, 11 chapters from the National Association of Hispanic Nurses collaborated to recruit participants. The CDC National 2009 H1N1 Flu Survey was adapted to measure behaviors and beliefs about immunizations of COVID-19. The Health Access Survey was used to measure social determinants of health. Instruments were available in both Spanish and English. Results: Participants (n=228) with higher education and health insurance tended to have less worry about taking the vaccine. Access to resources and practicing COVID-19 protective factors was positively associated. Alternative medicine and use of COVID-19 protective factors were negatively associated. Exposure to drugs and violence was associated with a decrease in likelihood to pursue a vaccine. Conclusions: Latinx need education about COVID-19 and vaccinations. Access to health care services must be available. Results highlight the importance of careful measurement when assessing social determinants of health among Latinx.

Introduction Patients with hematological malignancies, including multiple myeloma (MM), experience sub-optimal responses to SARS-CoV-2 vaccination. Monoclonal Gammopathy of Undetermined Significance (MGUS) and Smoldering Multiple Myeloma (SMM) are precursors to MM and exhibit altered immune cell composition and function. The SARS-CoV-2 pandemic and the subsequent population-wide vaccination represent an opportunity to study the real-life immune response to a common antigen. Here, we present updated results from the IMPACT study, a study we launched in November 2020 to characterize the effect of plasma cell premalignancy on response to SARS-CoV-2 vaccination (vx). Methods We performed: (i) ELISA for SARS-CoV-2-specific antibodies on 1,887 peripheral blood (PB) samples (237 healthy donors (HD), and 550 MGUS, 947 SMM, and 153 MM patients) drawn pre- and post-vx; (ii) single-cell RNA, T cell receptor (TCR), and B cell receptor (BCR) sequencing (10x Genomics) on 224 PB samples (26 HD, and 20 MGUS, 48 SMM, and 24 MM patients) drawn pre- and post-vx; (iii) plasma cytokine profiling (Olink) on 106 PB samples (32 HD, and 38 MGUS and 36 SMM patients) drawn pre- and post-vx; and (iv) bulk TCR sequencing (Adaptive Biotechnologies) on 8 PB samples from 4 patients (2 MGUS, 2 SMM) drawn pre- and post-vx. Results Patients with MGUS and SMM achieved comparable antibody titers to HD two months post-vx. However, patient titers waned significantly faster, and 4 months post-vx we observed significantly lower titers in both MGUS (Wilcoxon rank-sum, p=0.030) and SMM (p=0.010). These results indicate impaired humoral immune response in patients with MGUS and SMM.At baseline, the TCR repertoire was significantly less diverse in patients with SMM compared to HD (Wilcoxon rank-sum, p=0.039), while no significant difference was observed in the BCR repertoire (p=0.095). Interestingly, a significant increase in TCR repertoire diversity was observed post-vx in patients with SMM (paired t-test, p=0.014), indicating rare T cell clone recruitment in response to vaccination. In both HD and patients, recruited clones showed upregulation of genes associated with CD4+ naïve and memory T cells, suggesting preservation of the T cell response in SMM, which was confirmed by bulk TCR-sequencing in 4 patients.Lastly, by cytokine profiling, we observed a defect in IL-1β and IL-18 induction post-vx in patients with SMM compared to HD (Wilcoxon rank-sum, p=0.047 and p=0.015, respectively), two key monocyte-derived mediators of acute inflammation, suggesting an altered innate immune response as well. Conclusion Taken together, our findings highlight that despite the absence of clinical manifestations, plasma cell premalignancy is associated with defects in both innate and adaptive immune responses. Therefore, patients with plasma cell premalignancy may require adjusted vaccination strategies for optimal immunization. Citation Format: Yoshinobu Konishi, Romanos Sklavenitis-Pistofidis, Michelle P. Aranha, Ting Wu, Hong Yue, Elizabeth D. Lightbody, Mahshid Rahmat, Michael Timonian, Shohreh Varmeh, Daniel Heilpern-Mallory, Michael P. Agius, Nang K. Su, Jacqueline Perry, Erica Horowitz, Maya I. Davis, Anna V. Justis, Radosław P. Nowak, Mark Hamilton, Daniel Auclair, Catherine R. Marinac, Eric S. Fischer, Gad Getz, Irene M. Ghobrial. Altered immune response to vaccination in patients with plasma cell premalignancy [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 796.

Prevalence estimates for monoclonal gammopathy of undetermined significance (MGUS) are based on predominantly White study populations screened by serum protein electrophoresis supplemented with immunofixation electrophoresis. A prevalence of 3% is reported for MGUS in the general population of European ancestry aged 50 years or older. MGUS prevalence is two times higher in individuals of African descent or with a family history of conditions related to multiple myeloma. We aimed to evaluate the prevalence and clinical implications of monoclonal gammopathies in a high-risk US population screened by quantitative mass spectrometry.We used quantitative matrix-assisted laser desorption ionisation-time of flight (MALDI-TOF) mass spectrometry and EXENT-iQ software to screen for and quantify monoclonal gammopathies in serum from 7622 individuals who consented to the PROMISE screening study between Feb 26, 2019, and Nov 4, 2021, and the Mass General Brigham Biobank (MGBB) between July 28, 2010, and July 1, 2021. M-protein concentrations at the monoclonal gammopathy of indeterminate potential (MGIP) level were confirmed by liquid chromatography mass spectrometry testing. 6305 (83%; 2211 from PROMISE, 4094 from MGBB) of 7622 participants in the cohorts were at high risk for developing a monoclonal gammopathy on the basis of Black race or a family history of haematological malignancies and fell within the eligible high-risk age range (30 years or older for PROMISE cohort and 18 years or older for MGBB cohort); those over 18 years were also eligible if they had two or more family members with a blood cancer (PROMISE cohort). Participants with a plasma cell malignancy diagnosed before screening were excluded. Longitudinal clinical data were available for MGBB participants with a median follow-up time from serum sample screening of 4·5 years (IQR 2·4-6·7). The PROMISE study is registered with ClinicalTrials.gov, NCT03689595.The median age at time of screening was 56·0 years (IQR 46·8-64·1). 5013 (66%) of 7622 participants were female, 2570 (34%) male, and 39 (1%) unknown. 2439 (32%) self-identified as Black, 4986 (65%) as White, 119 (2%) as other, and 78 (1%) unknown. Using serum protein electrophoresis with immunofixation electrophoresis, the MGUS prevalence was 6% (101 of 1714) in high-risk individuals aged 50 years or older. Using mass spectrometry, we observed a total prevalence of monoclonal gammopathies of 43% (1788 of 4207) in this group. We termed monoclonal gammopathies below the clinical immunofixation electrophoresis detection level (0·2 g/L) MGIPs, to differentiate them from those with higher concentrations, termed mass-spectrometry MGUS, which had a 13% (592 of 4207) prevalence by mass spectrometry in high-risk individuals aged 50 years or older. MGIP was predominantly of immunoglobulin M isotype, and its prevalence increased with age (19% [488 of 2564] for individuals aged50 years, 29% [1464 of 5058] for those aged ≥50 years, and 37% [347 of 946] for those aged ≥70 years). Mass-spectrometry MGUS prevalence increased with age (5% [127 of 2564] for individuals aged50 years, 13% [678 of 5058] for those aged ≥50 years, and 18% [173 of 946] for those aged ≥70 years) and was higher in men (314 [12%] of 2570) compared with women (485 [10%] 5013; p=0·0002), whereas MGIP prevalence did not differ significantly by gender. In those aged 50 years or older, the prevalence of mass spectrometry was significantly higher in Black participants (224 [17%] of 1356) compared with the controls (p=0·0012) but not in those with family history (368 [13%] of 2851) compared with the controls (p=0·1008). Screen-detected monoclonal gammopathies correlated with increased all-cause mortality in MGBB participants (hazard ratio 1·55, 95% CI 1·16-2·08; p=0·0035). All monoclonal gammopathies were associated with an increased likelihood of comorbidities, including myocardial infarction (odds ratio 1·60, 95% CI 1·26-2·02; p=0·00016 for MGIP-high and 1·39, 1·07-1·80; p=0·015 for mass-spectrometry MGUS).We detected a high prevalence of monoclonal gammopathies, including age-associated MGIP, and made more precise estimates of mass-spectrometry MGUS compared with conventional gel-based methods. The use of mass spectrometry also highlighted the potential hidden clinical significance of MGIP. Our study suggests the association of monoclonal gammopathies with a variety of clinical phenotypes and decreased overall survival.Stand Up To Cancer Dream Team, the Multiple Myeloma Research Foundation, and National Institutes of Health.

Background Few prior studies have investigated the latent class structure of PTSD using DSM-5 symptoms. Methods To describe latent PTSD profiles among women who resided in Deepwater Horizon Oil Spill (DHOS)-affected coastal Louisiana communities, we used data from women enrolled in The Women and Their Children's Health (WaTCH) Study. Latent profile analysis was performed on the 20-item PTSD Checklist for DSM-5 (PCL-5) and model fit statistics for 2-class through 6-class solutions were compared. The pseudo-class draws method was employed on the best class solution to compare key covariates (including demographics, mental health indicators, DHOS exposure indicators, and trauma exposures) across classes. Results Among 1997 women (mean age 46.63 ± 12.14 years, 56.8% white, mean trauma categories 6.09 ± 2.98, 9.55% previously diagnosed with PTSD), model fit statistics supported a five-class solution: low symptoms (mean PCL-5 = 4.10), moderate without mood alterations (mean = 19.73), moderate with mood alterations (mean = 34.24), severe without risk-taking (mean = 55.75), and severe with risk-taking (mean = 53.80). Women in the low-symptom class were significantly more likely to be white, have finished high school, have an income of at least $40,001 per year, be married or living with a partner, and endorse fewer trauma categories than women in the four symptomatic classes. Women with moderate to severe symptoms often had co-morbid depressive symptoms and no prior PTSD diagnosis. Limitations This study was limited by use of self-reported data and one-time assessment of PTSD symptoms. Discussion Five distinct latent profiles of DSM-5 PTSD symptoms consisted of notably different individuals. Most affected women did not report prior PTSD diagnosis. Future research and practice identifying and addressing barriers to care for trauma-affected women in these communities is warranted.

This case focuses on a novice principal who advocates for a student who was assigned to the first grade for 3 consecutive years. As the instructional leader of the school, the novice principal is troubled by ethics and social justice issues involved to make the decision to assign the student to his age-appropriate grade. The student was placed in the exceptional students’ program to receive services for a specific learning disability in reading and writing during his first year returning to public school. The student will enter the second grade at the age of 9 years. The superintendent does not support the novice principal. The novice principal now has to decide next steps as a transformative leader in the district.

Background: Multiple Myeloma (MM) is a hematological malignancy characterized by abnormal proliferation of terminally differentiated plasma cells (PCs) in the bone marrow (BM). MM is almost always preceded by the precursor stage smoldering multiple myeloma (SMM). BM biopsies are useful to monitor disease progression, but they are invasive and not routinely collected from patients for disease monitoring during precursor stages. Profiling circulating tumor cells (CTCs) from peripheral blood (PB) could aid early detection, disease monitoring, and biomarker identification to predict patients at high risk of progression that may benefit from early therapeutic intervention. Methods: Paired PB and BM aspirates were collected from 40 SMM patients enrolled in the PCROWD study (IRB #14-174) at Dana-Farber Cancer Institute. Malignant PCs were enriched by magnetic bead-based methods and underwent 5’ single-cell RNA sequencing (scRNA-seq) and single-cell B-cell receptor sequencing (scBCR-seq) (10x Genomics). Results: We analyzed 105,246 BM PCs and 33,234 PB PCs from 15 patients. To differentiate malignant from normal PCs, we used clonal V(D)J rearrangements, assessed by concurrent scBCR-seq. A total of 86,986 BM tumor cells and 8,718 CTCs were captured. A median of 5, 26, and 47 CTCs were present per mL of blood from low, intermediate, and high-risk SMM patients as defined by the International Myeloma Working Group (IMWG) “20/2/20” criteria, suggesting sequencing-based CTC enumeration corresponds to prognosis. High levels of driver genes commonly upregulated in patients with specific translocations, including CCND1 and MAF, were detected in both BM tumor and CTC clusters in 3 patients with t(11;14) and t(14;16) confirmed by fluorescence in situ hybridization (FISH) clinical testing, and 2 additional patients with inconclusive FISH results (Wilcoxon, q Conclusions: This study highlights the utility of scRNA-seq for molecular profiling of CTCs, even in asymptomatic low tumor burden disease. Additional analyses are ongoing in the expanded cohort of 40 patients with paired samples to help gain further insight into CTC heterogeneity. Overall, this study will help enable the design of new molecular liquid biopsy-based approaches to diagnosis, disease monitoring, and biological insights to improve treatment strategies for precursor myeloma patients. Citation Format: Elizabeth D. Lightbody, Danielle T. Firer, Romanos Sklavenitis-Pistofidis, Michael Agius, Ankit K. Dutta, Michelle Aranha, Jean-Baptiste Alberge, Laura Hevenor, Nang Kham Su, Cody Boehner, Erica Horowitz, Jacqueline Perry, Anna Cowan, Hadley Barr, Anna Justis, Daniel Auclair, Catherine R. Marinac, Gad Getz, Irene Ghobrial. Single-cell RNA sequencing of rare circulating tumor cells in precursor myeloma patients reveals molecular underpinnings of tumor cell circulation [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 641.

Introduction: Patients with hematologic malignancies, including multiple myeloma (MM), experience worse SARS-CoV-2 infection outcomes and sub-optimal vaccine responses. Monoclonal gammopathy of undetermined significance (MGUS) and smoldering multiple myeloma (SMM) precede MM and affect ~5% of individuals age >=50. We previously showed that individuals with MGUS and SMM exhibit immune dysregulation. Here, we investigate the immune response to SARS-CoV-2 vaccination in these asymptomatic but potentially immunocompromised individuals. Methods: The IMPACT study (IRB #20-332) is a prospective study at Dana-Farber Cancer Institute in collaboration with MMRF, which enrolled individuals nationwide with a diagnosed plasma cell dyscrasia and healthy individuals. As of October 2021, 3,005 individuals completed a questionnaire regarding prior infection or vaccination. We obtained 1,350 blood samples from 628 participants and analyzed anti-SARS-CoV-2 IgG antibody titer by ELISA. Results: 2,771 (92%) participants were fully vaccinated (2 doses BNT162b2 or mRNA-1273; 1 dose Ad26.COV2.s), 269 (9%) had received a 3rd mRNA vaccine dose, and 234 (8%) were unvaccinated. 1,387 (46%) and 1,093 (36%) participants received mRNA vaccines (BNT162b2 and mRNA-1273), and 139 (5%) participants received an adenovirus vector vaccine (Ad26.COV2.S). 34 (1%) individuals reported SARS-CoV-2 infection after full vaccination. We measured antibody titers in 201 MGUS, 223 SMM, 40 smoldering Waldenstrom macroglobulinemia (SWM), 64 MM, and 100 healthy controls. Multiple linear regression model estimated the association between various clinical variables and post-vaccination antibody titers. As previously reported, having MM was associated with low antibody titer (p < 0.001). Of note, having SMM, regardless of risk stratification by 2/20/20 criteria, was also associated with low antibody titers, indicating that even low-risk SMM patients have a poor response to vaccination. MGUS and SWM diagnoses were not significantly associated with antibody titers. Additionally, male sex (p < 0.010), elapsed time after vaccination (p < 0.001), and BNT162b2 vaccine (p < 0.001) were associated with low antibody titers. SARS-CoV-2 infection prior to vaccination was associated with high antibody titers. We identified 25 patients (6 MGUS, 10 SMM, 2 SWM, 7 MM) who submitted blood samples after both the 2nd and 3rd dose. In these patients we observed a significant increase in antibody titer after a 3rd dose (p = 0.002). We also observed that antibody titers of patients after a 3rd dose (13 MGUS, 12 SMM, 2 SWM, 31 MM) were comparable to that of healthy individuals after a 2nd dose (p = 0.833). Conclusion: Our data indicates that suboptimal response to SARS-CoV-2 does not only occur with MM and cancer patients receiving therapy but also in precursor asymptomatic patients including low-risk SMM. Citation Format: Yoshinobu Konishi, Romanos Sklavenitis-Pistofidis, Hong Yue, Federico Ferrari, Massimiliano Russo, Robert A. Redd, Jacqueline Perry, Erica Horowitz, Anna V. Justis, Nader A. Shayegh, Elizabeth D. Lightbody, Shohreh Varmeh, Radoslaw P. Nowak, Mark Hamilton, Daniel Auclair, Catherine R. Marinac, Lorenzo Trippa, Eric S. Fischer, Irene M. Ghobrial. Humoral SARS-CoV-2 response in asymptomatic precursor plasma cell dyscrasia patients: IMPACT study results [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 5277.

Introduction: Patients with hematological malignancies exhibit inferior response to SARS-CoV2 vaccination, compared to healthy individuals, however little is known about patients with precursor hematological malignancies and the cellular underpinnings of vaccination response. Monoclonal Gammopathy of Undetermined Significance (MGUS) and Smoldering Myeloma (SMM) are plasma cell premalignancies that precede Multiple Myeloma (MM) and exhibit signs of immune dysregulation; they affect approximately 5% of the population over 50 years of age, who remain largely undiagnosed, due to lack of screening. In November 2019, we launched the IMPACT study to characterize the immune response to SARS-CoV2 vaccination in patients with plasma cell dyscrasias and healthy individuals. Methods: We performed single-cell RNA-sequencing on 224 peripheral blood mononuclear cell samples drawn from 118 IMPACT (IRB #20-332) participants with MGUS (n=20), SMM (n=48), or MM (n=24), as well as healthy individuals (n=26). Samples were collected before vaccination and after 2 doses of BNT162b2 (Pfizer-BioNtech) (n=123), mRNA-1273 (Moderna) (n=83) or 1 dose of Ad26.COV2.S (Janssen) (n=14). Results: Overall, we sequenced 2,025,611 cells from 224 samples of 118 patients with MGUS, SMM, MM and healthy individuals pre- and post-vaccination for SARS-CoV2, and profiled 553,082 T-cells, 95,392 B-cells, 74,394 NK cells, 195,371 Monocytes, and 35,236 Dendritic cells (DC). We identified activated clusters of B-cells, NK cells and DCs expressing genes such as CD83, CD69, CXCR4, and genes related to the NF-kB and AP-1 pathways. We compared cell type abundances pre- and post-vaccination within each participant population and found that activated CD83+ cells significantly increased post-vaccination in healthy individuals and patients with MGUS (paired t-test, q < 0.1), but not in patients with SMM or overt MM. At baseline, patients with SMM and MM had significantly fewer memory B-cells and significantly more cytotoxic T-cells and NK cells, compared to healthy individuals (Wilcoxon, q < 0.1), which could partly explain the differences observed post-vaccination. Patients with MM also had significantly higher levels of tolerogenic IL-10-expressing DCs (DC10) at baseline (Wilcoxon, q < 0.1), which could be dampening antigen-specific T-cell responses. Conclusion: We identified a significant expansion of activated B-cell, NK cell and DC subpopulations expressing CD83, CD69 and CXCR4, following vaccination in healthy individuals and patients with MGUS, but less so in patients with SMM and overt MM. Our results provide insight into the cellular mechanisms of immune response to SARS-CoV2 vaccination in healthy individuals and patients with precursor plasma cell malignancies and suggest that asymptomatic individuals with SMM may exhibit inferior response to vaccination. Citation Format: Romanos Sklavenitis-Pistofidis, Yoshinobu Konishi, Michelle Aranha, Mahshid Rahmat, Ting Wu, Michael Timonian, Shohreh Varmeh, Daniel Heilpern-Mallory, Michael P. Agius, Nang K. Su, Elizabeth D. Lightbody, Jacqueline Perry, Erica M. Horowitz, Anna V. Justis, Daniel Auclair, Catherine R. Marinac, Eric S. Fischer, Gad Getz, Irene M. Ghobrial. Single-cell RNA-sequencing for immune profiling of SARS-CoV2 vaccine response in healthy individuals and patients with precursor plasma cell malignancies [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 3582.

Introduction: Multiple myeloma (MM) is consistently preceded by two precursor conditions, monoclonal gammopathy of undetermined significance (MGUS) and smoldering multiple myeloma (SMM). The distinctions between MGUS, SMM, and MM rely on clinical values with inherent variation relating to tumor burden quantified from bone marrow biopsies, a measure subject to inconsistencies in location, timing, and pathologist interpretation. These challenges limit the potential of current standardized risk criteria and advocate for models that examine precursor disease kinetics. We thus developed a risk model that leverages dynamic changes in markers of precursor disease to improve clinical ability to predict time to disease progression. Methods: To model the evolution of progression risk, we built PANGEA, an international retrospective cohort of precursor patients with baseline and serial time points of clinical and biological variables. This cohort comprises 1095 SMM patients, 254 (23%) of which progressed to MM. Using this cohort, we modeled progression to MM with Cox regression using time-dependent and continuous clinical variables. The model was trained on a subset of data restricted to patients of the Dana-Farber Cancer Institute (DFCI) and validated its performance by computing the c-statistic in a sub-cohort independent from the DFCI training cohort. Results: The PANGEA cohort was first used to validate current models of SMM disease progression. We validated the 20/2/20 International Myeloma Working Group criteria for SMM patients using binary cutoffs of initial measurements (baseline model), and then extended this model, allowing for re-stratification by the 20/2/20 criteria over time (dynamic model). We then assessed whether rates of change in a set of myeloma-specific clinical variables unrestricted to those of the 20/2/20 criteria improved the predictive ability of the model. This improved our progression prediction as indicated by a c-statistic increase of more than 10% with respect to both 20/2/20 models (baseline and dynamic). Specifically, changes in disease indicators such as age and creatinine are highly predictive of imminent disease progression (p-value < 0.01). Finally, we clustered patients based on latent trajectories of these time-varying clinical variables and included the trajectory classes in the Cox regression. The resulting multivariable, dynamic algorithm is a dramatic improvement over current clinical standards in predicting progression from SMM to MM disease. Conclusion: The PANGEA multivariable algorithm’s use of continuous clinical variables enhances progression risk predictions in SMM. These findings demonstrate that disease progression from SMM to MM, which likely occurs by the acquisition of sequential changes to the plasma cell clone, can be tracked by trends in clinical values, thus improving prognostication for precursor patients. Citation Format: Annie Cowan, Habib El-Khoury, Federico Ferrari, Samuel S. Freeman, Robert Redd, Jacqueline Perry, Vidhi Patel, Priya Kaur, Hadley Barr, Katelyn Downey, David Argyelan, Anna V. Justis, David J. Lee, Elizabeth D. Lightbody, Foteini Theodorakakou, Despina Fotiou, Nikolaos Kanellias, Christine Liacos, Gad Getz, Lorenzo Trippa, Catherine Marinac, Efstathios Kastritis, Dimopoulos Meletios, Irene Ghobrial. Predictive modeling of smoldering multiple myeloma progression to multiple myeloma by continuous variable analysis [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 2259.

Background: Monoclonal gammopathy of undetermined significance (MGUS) is a premalignant condition of multiple myeloma (MM) traditionally identified by serum protein electrophoresis (SPEP) and immunofixation (IFX). Recently, novel, ultra-sensitive mass spectrometry (MS)-based approaches have allowed for monoclonal (M)-protein detection at concentrations below SPEP levels. MGUS has only few known risk factors implicated in its development and progression. Thus, we analyze MS results of the PROMISE nationwide U.S. screening study to evaluate risk factors for (1) MGUS at traditional SPEP/IFX levels of detection and (2) low-level monoclonal gammopathies, which bear uncertain etiology and clinical significance. Methods: PROMISE enrolled individuals age ≥40 who are Black and/or have a first-degree relative with a blood cancer or MM precursor condition. Those with ≥2 first-degree relatives were eligible at age ≥18. Participants were screened for monoclonal gammopathy by MALDI-TOF MS and provided a survey querying metabolic comorbidities and lifestyle. M-protein concentrations ≥0.02 g/dL were considered traditionally-defined MGUS, whereas M-proteins Results: 1,893 screened participants completed the survey. MGUS and MGIP were detected in 13.4% and 22.0% of Blacks and 8.6% and 26.7% of individuals with family history. Adjusting for sex, age at screening, income, and education, obesity or BMI of ≥30 was associated with MGUS (OR, 1.55; 95% CI, 1.08-2.21), compared to BMI 6 hours/day. Physical activity (metabolic equivalents/week), smoking status (current, past, never), alcohol consumption (g/day) had no associations with MGUS. No risk factor associations were found for MGIP. Conclusion: In screening a high-risk population by mass spectrometry, we found associations of both traditionally established (obesity) and novel risk factors (diabetes, hypertension, short sleep) with MGUS. None of these exposures were associated with MGIP despite finding a high prevalence of MGIP in Blacks and individuals with family history, suggesting that these risk factors may not be etiologically involved in MGIP development but possibly its clonal expansion to more advanced stages. Citation Format: David J. Lee, Habib El-Khoury, Jean-Baptiste Alberge, D.J. Sakrikar, David Barnidge, Mark C. Perkins, Stephen Harding, Jacqueline Perry, Maya I. Davis, Julia Amstutz, Erica Horowitz, Timothy R. Rebbeck, Irene M. Ghobrial, Catherine R. Marinac. Obesity, metabolic comorbidities, and lifestyle factors and their association with monoclonal gammopathies in a high-risk screened population: Results of the PROMISE study [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 3651.

Background Multiple myeloma (MM) evolves from monoclonal gammopathy of undetermined significance (MGUS), a clinically detectable but asymptomatic premalignant phase seen in ~3% of the general population 50 years of age or older. The prevalence of MGUS has not been described in a population at high risk of developing MM, specifically Black/African American (AA) individuals or first-degree relatives of patients with hematologic malignancies (HM). In 2019, we launched the first nationwide US screening study for individuals at high risk of MM to help better identify what population would benefit most from screening and early intervention for precursor MM stages. We aim to assess the prevalence of MGUS in a population at high risk of MM and characterize clinical variables of individuals who screen positive. Here, we report interim screening data on the first 2,960 participants. Methods Individuals aged 40 or older with an additional MM risk factor are eligible to be screened in the PROMISE Study. High-risk individuals include Black/AAs and those with a first-degree relative diagnosed with a hematologic malignancy or a precursor condition to MM. Blood from all participants was analyzed via serum protein electrophoresis, immunofixation, and Optilite® to measure the serum free light chains (sFLC), IgG, IgA and IgM. Results were returned to all participants, and those who tested positive for a monoclonal gammopathy (MGUS/SMM) were referred to a hematologist for clinical follow-up and invited to periodically complete epidemiologic exposure and psychosocial questionaries, including a 4-item cancer worry questionnaire and the RAND 36-item Short Form Survey (SF-36). To investigate the use of the higher-sensitivity matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS) with the Optilite® IgG, IgA, IgM and sFLC results as a screening test for all participants, we rescreened 1,092 samples from PROMISE. The Binding Site Group proprietary software was used for the analysis of the combined MS/Optilite® results, allowing for the detection and quantification of M-protein. Heavy-Chain MGUS (HC-MGUS) was defined by the presence of one or more paired heavy and light chain monoclonal peaks detected by MS. Pairing was based on mass to charge ratio of identified peaks. To enrich the PROMISE cohort with Black/AA individuals, we identified and screened 1,868 Black/AA additional individuals from the Mass General Brigham (MGB) Biobank who met the PROMISE enrollment criteria. Screening was performed by MS/Optilite®, and results have not been returned to participants. Results We screened 2,960 participants with the combined MS/Optilite® approach. We report here the prevalence of HC-MGUS and plan on presenting the estimated rate of light chain MGUS in our cohort, at the meeting. We detected HC-MGUS in 9.6% (95% CI: 8.6-11%) of our cohort, with a prevalence of 10% (95% CI: 8.3-12%) in the PROMISE cohort and 9.4% (95% CI: 8.1-11%) in the MGB cohort (Table 1 and Figure 1). HC-MGUS prevalence increased with age in high-risk individuals from 4.9% (CI: 3.3-6.9%) for participants aged 40-49 to 13% (CI: 10-17%) in the 70-79 range (P < 1.2E-5). Among monoclonal HC-MGUS, we found 65% IgG, 18% IgM, and 18% IgA. M-spike was quantified in 97% of samples. Median M-spike concentration was, 0.058g/dL (max. 2.6g/dL) for IgG, 0.0043g/dL (max. 0.6g/dL) for IgM, and 0.067g/dL (max. 0.8g/dL) for IgA. In the Promise cohort, no significant change in cancer worry was observed across the pre- and post-screening interval among participants who screened positive (P = 0.52). Health-related quality of life, as measured by the SF-36, was not significantly different in screen-positive vs. screen-negative individuals for any of the eight subscales (all P > 0.20). Conclusions We present the largest dataset on monoclonal gammopathy prevalence and screening in individuals at high risk for MM, and more specifically the largest cohort of Black/AA, using a novel high-sensitivity testing approach. Our results confirm that older adults who are Black/AA or have a first-degree relative with an HM have a high prevalence MGUS and may benefit from precision screening approaches to allow for early detection and clinical intervention. Preliminary data on cancer worry and quality of life indicates that the psychosocial burden of screening in this population is likely minimal. Figure 1 Figure 1. Disclosures Sakrikar: The Binding Site: Current Employment. Krause: The Binding Site: Current Employment. Barnidge: The Binding Site: Current Employment. Bustoros: Takeda: Consultancy, Honoraria; Janssen, Bristol Myers Squibb: Honoraria, Speakers Bureau. Perkins: The Binding Site: Current Employment. Harding: The Binding Site: Current Employment, Membership on an entity's Board of Directors or advisory committees, Patents & Royalties. Kapoor: Ichnos Sciences: Research Funding; Amgen: Research Funding; Pharmacyclics: Consultancy; Takeda: Research Funding; Sanofi: Consultancy; Regeneron Pharmaceuticals: Research Funding; AbbVie: Research Funding; BeiGene: Consultancy; Sanofi: Research Funding; Karyopharm: Research Funding; Glaxo SmithKline: Research Funding; Karyopharm: Consultancy; Cellectar: Consultancy. Mo: Sanofi: Honoraria, Membership on an entity's Board of Directors or advisory committees; GSK: Consultancy, Membership on an entity's Board of Directors or advisory committees; BMS: Membership on an entity's Board of Directors or advisory committees; Epizyme: Consultancy; Eli Lilly: Consultancy; Janssen: Honoraria; Karyopharm: Honoraria, Membership on an entity's Board of Directors or advisory committees. Murray: The Binding Site: Patents & Royalties: Potential Royalties for use of mass spectrometry in M-protein detection. Getz: Scorpion Therapeutics: Consultancy, Current holder of individual stocks in a privately-held company, Membership on an entity's Board of Directors or advisory committees; IBM, Pharmacyclics: Research Funding. Marinac: JBF Legal: Consultancy; GRAIL Inc: Research Funding. Ghobrial: AbbVie, Adaptive, Aptitude Health, BMS, Cellectar, Curio Science, Genetch, Janssen, Janssen Central American and Caribbean, Karyopharm, Medscape, Oncopeptides, Sanofi, Takeda, The Binding Site, GNS, GSK: Consultancy.

Supplemental Digital Content is available in the text., Background. Many kidney transplant centers in the United States report both HLA class I and II antibodies detected by sensitive solid-phase assays (SPAs) to United Network for Organ Sharing as unacceptable antigens, significantly reducing the compatible donor organ pool and prolonging waiting time for highly sensitized patients. However, the clinical relevance of all detected donor-specific antibodies (DSAs) by SPA is not unequivocal, because fluorescence intensity does not always accurately reflect antibody pathogenicity. Our center does not exclude patients from transplantation based on DSA class II. Methods. We performed a retrospective analysis in 179 deceased-donor kidney transplant recipients with solely DSA class II before transplant and patients without DSA and compared graft survival, rejection, and clinical outcomes. Patient survival was also compared with matched controls on the waiting list. Results. Patients transplanted with DSA class II showed a clear survival benefit compared with matched patients who remained on dialysis or were waitlisted on dialysis/transplanted at 5 years (100%, 34%, and 73%, respectively). After a mean follow-up of 5.5 years, there was no significant difference in death-censored graft survival between transplanted patients without DSA and those with preformed DSA class II (adjusted HR 1.10; 95% confidence interval, 0.41–2.97), although the incidence of rejection was higher in recipients with DSA class II (adjusted HR 5.84; 95% confidence interval, 2.58–13.23; P < 0.001). Serum creatinine levels at 1, 3, and 5 years posttransplant did not differ between groups. No predictors of rejection were found, although patients who received basiliximab induction therapy had higher incidence of rejection (100%) compared with those who received antithymocyte globulin (52%). Conclusions. We conclude that for highly sensitized patients, deceased-donor kidney transplantation with DSA class II yields a survival benefit over prolonged waiting time on dialysis. Instead of listing DSA class II as unacceptable antigens, an individual approach with further immunologic risk assessment is recommended.

This thesis uses Benedict Anderson's theoretical contributions on the topic of national identity and Michel Foucault's contributions toward discourse analysis to perform a discursive analysis of Donald Trump's campaign speeches in which he exploits pre-existing anti-immigration sentiments among certain voters to gain political power. The research question addressed herein is: How has Donald Trump invoked the issue of national security to single out groups of immigrants as threats to U.S. national security, and what conditions exists so that he is able to do so in a way that enlists the support of a sizeable portion of the American public? First, this thesis works to put into context what drove post-World War II immigration in the U.S. to provide insight into what conditions lead to certain groups being encouraged or discouraged from immigrating. Second, I contrast Anderson's concept of nationalism with that of Samuel Huntington, whose idea of nationalism more closely aligns with Trump's nativist sense of national identity. Third, having put the history of U.S. immigration and the concept of national identity into context, I perform a discursive analysis of three of Trump's campaign speeches and tweets that focus on immigration and make problematic his racist, far-right ideology and its purpose toward the de-politicization and de-historicization of immigration as a national security and economic issue. I conclude by reminding the reader that allowing anti-immigrant discourse to become normalized without the burden of proof can lead to curbed freedoms under an authoritarian regime, a direction toward which Trump appears ready and willing to lead the American electorate. Master of Arts

Hydroxyl (OH) and hydroperxy (HO 2 ) radicals, collectively known as HO x , were measured during an intensive field study in January and February 2004 in New York City. Much less OH and HO 2 levels were observed than in the summer of 2001 at the same site. On average, the maximum daytime mixing ratios were 0.05 pptv (1.4×10 6 cm −3 ) for OH and 0.7 pptv for HO 2 , which were about one fifth of the levels in the summer of 2001. A zero-dimensional chemical model, based on the regional atmospheric chemical mechanism (RACM) and constrained by the measured concentrations of O 3 , NO, NO 2 , CO, SO 2 , speciated volatile organic compounds (VOCs) and meteorological parameters, was used to study the HO x chemistry in this environment. The model generally reproduced the daytime OH well, with a median measured-to-model ratio of 0.98. However, HO 2 was significantly under-predicted both at day and at night, with a median measured-to-model ratio of 6.0 during daytime. The discrepancy is pronounced when NO concentrations were high, a result that is consistent with some previous studies in urban environments. Photolysis of HONO was the dominant calculated HO x source during daytime; O 3 reactions with alkenes became the main calculated HO x source at night. The main calculated HO x sink was the OH reaction with NO 2 . The discrepancy between measured and modeled HO 2 may be caused by significant HO x production that is missing in the model. An additional HO 2 production of up to 3×10 7 cm −3 s −1 (1.1 pptv s −1 ), which is three times the calculated HO x production, is needed. This HO 2 production can come either from unknown new HO x production or from unknown HO 2 recycling that does not go through OH.

Since 1990s, a systematic program to measure air toxics has been active in New York State with monitors located both in urban and rural areas. In this study we examined the spatial and temporal characteristics of benzene, a known human carcinogen that is emitted by many source categories. The analysis indicates that ambient concentration levels of benzene have decreased by as much as 60% over this period not only in the ozone non-attainment area of New York City that had the reformulated gas (RFG) requirements, but also over the rest of the state as well. Although the rate of decrease appears to have flattened out in recent years, the annual average concentration levels are found to be above the health risk threshold even at the remote location, Whiteface Mountain, suggesting the need for further reductions in benzene emissions.

We aimed to improve the understanding of genotype-phenotype correlations in Rett syndrome (RS) by adopting a novel approach to categorising phenotypic dimensions - separating typicality of presentation, outcome severity and age of onset - and by classifying MECP2 mutations strictly by predicted functional attributes. MECP2 mutation screening results were available on 190 patients with a clinical diagnosis of RS (140 cases with classic RS, 50 with atypical RS). 135 cases had identified mutations. Of the 140 patients, 116 with classic RS (82.9%) had an identified mutation compared with 19 of 50 patients (38%) with an atypical presentation. Cases with early onset of regression and seizures, and those with clinical features that might indicate alternative aetiologies, were less likely to have mutations. Individuals with late truncating mutations had a less typical presentation than cases with missense and early truncating mutations, presumably reflecting greater residual function of MECP2 protein. Individuals with early truncating mutations had a more severe outcome than cases with missense and late truncating mutations. These findings held when restricting the analysis to cases over 15 years of age and classic cases only. Previous findings of variation in severity among the common mutations were confirmed. The approach to phenotypic and genotypic classification adopted here allowed us to identify genotype-phenotype associations in RS that may aid our understanding of pathogenesis and also contribute to clinical knowledge on the impact of different types of mutations.

There is epidemiological evidence that infection may play a role in the etiology of childhood leukemia in particular common B cell precursor acute lymphoblastic leukemia. A panel of 20 leukemic samples (panel 1) was examined for the presence of four lymphotropic herpesviruses using conventional molecular techniques. A second independent panel of 27 leukemic samples (panel 2), along with 28 control peripheral blood samples from children with other forms of cancer, was tested for the presence of the same four viruses using sensitive real-time quantitative PCR. While herpesvirus genomes were detected, they were present at very low levels; detection rates and levels were similar in the leukemic and control panels. In addition we surveyed 18 leukemic samples (five from panel 1, six from panel 2 and a further seven samples not previously analyzed) using a degenerate PCR assay capable of detecting the genomes of known herpesviruses plus putative new members of the family. No novel herpesvirus genomes were detected suggesting that a herpesvirus is unlikely to be etiologically involved as a transforming agent in common acute lymphoblastic leukemia.

Using dynamic surface electrode electromyography, we evaluated muscle activity in 13 male professional golfers during the golf swing. Surface electrodes were used to record the level of muscle activity in the right abdominal oblique, left abdominal oblique, right glu teus maximus, left gluteus maximus, right erector spi nae, left erector spinae, upper rectus abdominis, and lower rectus abdominis muscles during the golfer's swing. These signals were synchronized electronically with photographic images of the various phases of the golf swing; the images were recorded in slow motion through motion picture photography. The golf swing was divided into five phases: take away, forward swing, acceleration, early follow-through, and late fol low-through. Despite individual differences among the subjects' swings, we observed reproducible patterns of trunk muscle activity throughout all phases of the golf swing. Our findings demonstrate the importance of the trunk muscles in stabilizing and controlling the loading response for maximal power and accuracy in the golf er's swing. This study provides a basis for developing a rehabilitation program for golfers that stresses strengthening of the trunk muscles and coordination exercises.

The complete DNA sequence of equine herpesvirus 2 (EHV-2) strain 86/67 was determined. The genome is 184,427 bp in size and has a base composition of 57.5% G + C. Unusually for a herpesvirus, about a third of the sequence distributed in several large blocks appears not to encode proteins. The 79 open reading frames that were identified as probably polypeptide-coding are predicted to encode 77 distinct proteins. Amino acid sequence comparisons confirmed that EHV-2 is a gamma-herpesvirus that is genetically collinear with herpesvirus saimiri (HVS; a gamma 2-herpesvirus) and Epstein-Barr virus (EBV; a gamma 1-herpesvirus), with a closer relationship to the former. Moreover, EHV-2 specifies eight proteins that have counterparts in HVS but not in EBV and only a single protein that has a homologue in EBV but not in HVS (EBV BCRF1, which encodes an interleukin 10-like protein). EHV-2 also encodes three potential G protein-coupled receptors, one with a counterpart in HVS that is specific for alpha chemokines, another with a counterpart in human cytomegalovirus (a beta-herpesvirus), which is specific for beta chemokines, and a third that is assigned more tentatively and lacks detectable counterparts in other herpesviruses.

[1] Measurements of ambient formaldehyde (HCHO), related gases and particulate matter were carried out from the SUNY Albany mobile platform at the Queens College site in New York City (NYC) from 15 July to 3 August 2009. Ambient HCHO was measured using a quantum cascade laser (QCL) trace gas detector. HCHO concentrations ranged from 0.4 to 7.5 ppb with a mean value of 2.2 ± 1.1 ppb. Daily HCHO peaks were nearly always found between 1100 EST (Eastern Standard Time) and noontime throughout the sampling period. HCHO correlated strongly with NOx and black carbon during the traffic rush hours, but around noontime HCHO correlated much better with total oxidants (Ox = O3 + NO2). Using the diurnal pattern of HCHO/BC ratios, we estimated that 70% of HCHO present between 1200 EST to 1500 EST was produced by photochemical reactions. Sources of photochemically produced HCHO were calculated using measured concentrations of hydrocarbons, their reaction kinetics with OH radicals, and HCHO yields. These calculations indicated that isoprene oxidation was the dominant source of HCHO for this period at this site, responsible for 44%, followed by methane (25%) and propene (18%). To assess the impact of HCHO as a radical source, the HOx production rates from HCHO, HONO, O3 photolysis, and alkenes +O3 were calculated as well. Daily averaged HOx production rates from HONO, HCHO, O3 photolysis and alkenes +O3 were 8.6 × 106, 2.3 × 106, 1.7 × 106, 2.1 × 105 molecules cm−3 s−1, respectively, contributing 67, 18, 13 and 2% to the overall daily HOx radical budget from these precursors.

Epidemiological evidence suggests that infection is involved in the etiology of common acute lymphoblastic leukemia, either by stimulating an inappropriate immune response or in the form of a classical transforming agent. In an attempt to elucidate the role that infection is playing in this disease, we used representational difference analysis (RDA) to examine tumor samples for the presence of exogenous genomes. Twenty RDA experiments were carried out, using four different restriction enzymes, but no exogenous sequences were identified within leukemic cells. These results suggest that it is unlikely that a single, direct transforming agent is involved in the pathogenesis of common acute lymphoblastic leukemia.

The Epstein-Barr virus (EBV) is associated with a proportion of Hodgkin lymphoma (HL) cases, and this association is believed to be causal. The aetiology of cases lacking EBV in the tumour cells (EBV HRS-ve), which make up the majority of cases in western countries, is obscure. It has been suggested that EBV may also cause these tumours by using a hit-and-run mechanism. Support for this idea comes from the finding that most young adult patients, who are likely to have a good immune response to EBV, have EBV HRS-ve HL. We investigated this possibility using a combined serologic and molecular approach. Analysis of EBV seroprevalence rates in an epidemiologic study of young adult HL revealed that cases with EBV HRS-ve HL were more likely to be EBV-seronegative than controls. Furthermore, additional studies clearly showed that some HL patients have never been infected by EBV. Quantitative PCR was used to look for the presence of deleted EBV genomes in a series of adult cases with both EBV HRS+ve and HRS-ve HL. Subgenomic fragments were detected in equimolar proportions. This study, therefore, found no evidence to support the idea that a hit-and-run mechanism involving EBV plays a role in the pathogenesis of HL.

The Epstein-Barr virus (EBV) is associated with a proportion of cases of Hodgkin disease (HD) and this association is believed to be causal. Epidemiological studies suggest that an infectious agent is involved in the aetiology of young adult HD, however, cases in this age group are less likely to have EBV-associated disease than cases diagnosed in early childhood or older adult years. Molecular studies have failed to find a consistent association between HD and other candidate viruses, and the aetiology of non-EBV-associated cases remains obscure. We looked for evidence of herpesvirus infection in samples of non-EBV-associated HD using a highly sensitive, degenerate PCR assay. Despite exhaustive sequence analysis of PCR products, no novel herpesviruses were identified. These results suggest that it is extremely unlikely that a novel herpesvirus is involved in the pathogenesis of non-EBV-associated HD.

The complete DNA sequence of equine herpesvirus-4 (EHV-4) strain NS80567 was determined. The genome is 145597 bp in size and consists of a long unique region (UL, 112398 bp) flanked by a short inverted repeat (TRL/IRL, 27 bp) linked to a short unique region (Us, 12789 bp) flanked by a substantial inverted repeat (TRs/IRs, 10178 bp). EHV-4 is predicted to contain 76 different genes; three of these are present twice in TRs/IRs, giving a total of 79 genes. The closely related virus equine herpesvirus-1 (EHV-1) also possesses 76 different genes corresponding to those of EHV-4, but has a total of 80 genes because four are present twice in TRs/IRs. Interpretations of the coding capacity of the EHV-4 and EHV-1 genomes were refined by comparing the complete DNA sequences.

The purpose of this study was to determine which exercises most effectively use the scapular muscles. Eight muscles in 9 healthy subjects were studied with indwelling electromyographic electrodes and cinema tography while performing 16 exercises. The 8 muscles studied were the upper, middle, and lower trapezius; levator scapula; rhomboids; pectoralis minor; and the middle and lower serratus anterior. Each exercise was divided into arcs of motion and the electromyographic activity was quantified as a percentage of the maximal manual muscle test. The optimal exercises for each muscle were identified based on intensity (greater than 50% maximal manual muscle test) and duration (over at least 3 consecutive arcs of motion) of the muscle activity. Twelve of the exercises qualified as top exer cises for all of the muscles. On further analysis, a group of 4 exercises was shown to make up the core of a scapular muscle strengthening program. Those 4 ex ercises include scaption (scapular plane elevation), row ing, push-up with a plus, and press-up.

Stiff-legged gait, ascribed to limited knee flexion during swing in spastic paresis, has previously received little detailed investigation. In this study, data from 23 patients referred for dynamic electromyographic evaluation of spastic stiff-legged gait were analyzed to identify timing of the activity of eight muscles during the gait cycle. Stride characteristics and foot switch data were also analyzed. Inappropriate activity in at least one of the quadriceps muscles during the preswing and/or initial swing phases was found in all 23 patients. Nine patients (39%) had hamstring activity during preswing. This group of 9, compared with the other 14 patients, had a significant reduction in average gait velocity and stride length (P less than 0.05) suggesting that preswing hamstring activity in stiff-legged gait may be counterproductive. No relation was found between biceps femoris (short head) activity and the amount of peak knee flexion attained in swing indicating that other factors are more important in attaining knee flexion. Delayed heel rise was observed in 21 patients (91%), which could imply insufficient calf muscle strength. Further, patients with markedly delayed heel rise achieved less peak knee flexion in swing than patients with normal or only moderately delayed heel rise (P less than 0.05). This may support the notion that adequate calf muscle strength is important in initiating knee flexion in the terminal stance/preswing phase. Results from this study provide preliminary quantitative information about stiff-legged gait that may prove useful in guiding management techniques.