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Current therapies for relapsed/refractory (R/R) pediatric myeloid neoplasms are inadequately effective. Real-world data (RWD) can improve care by augmenting traditional studies and include individuals not eligible for clinical trials. The Therapeutic Advances in Childhood Leukemia and Lymphoma (TACL) consortium recently completed T2016-003, a phase 1 study of decitabine, vorinostat, fludarabine, cytarabine, and granulocyte colony-stimulating factor (G-CSF) in R/R acute myeloid leukemia (AML), which added epigenetic drugs to a cytotoxic backbone. We report results of RWD from six centers that treated 28 pediatric patients (26 with AML, two with other myeloid neoplasms) identically to the TACL study but who were not enrolled. This allowed unique analyses and the ability to compare data with the 35 TACL study patients. The overall response rate (ORR) (complete response [CR] plus CR with incomplete count recovery) among 26 RWD evaluable patients was 65%. The ORR of 13 patients with relapsed AML with epigenetic alterations was 69% (T2016-003 + RWD: 68%, n = 25), of eight patients with refractory AML was 38% (T2016-003 + RWD: 41%, n = 17) and of five patients with therapy-related AML (t-AML) was 80% (T2016-003 + RWD: 75%, n = 8). The mean number of Grade 3/4 toxicities experienced by the T2016-003-eligible RWD population (n = 22) (one per patient-cycle) was not meaningfully different than those (n = 6) who would have been TACL study-ineligible secondary to comorbidities (two per patient-cycle). Overall, this therapy was well tolerated and effective in pediatric patients with R/R myeloid neoplasms, particularly those with epigenetic alterations, t-AML, and refractory disease.

Survival outcomes for relapsed/refractory pediatric acute myeloid leukemia (R/R AML) remain dismal. Epigenetic changes can result in gene expression alterations which are thought to contribute to both leukemogenesis and chemotherapy resistance. We report results from a phase I trial with a dose expansion cohort investigating decitabine and vorinostat in combination with fludarabine, cytarabine, and G-CSF (FLAG) in pediatric patients with R/R AML [NCT02412475]. Thirty-seven patients enrolled with a median age at enrollment of 8.4 (range, 1-20) years. There were no dose limiting toxicities among the enrolled patients, including two patients with Down syndrome. The recommended phase 2 dose of decitabine in combination with vorinostat and FLAG was 10 mg/m2 . The expanded cohort design allowed for an efficacy evaluation and the overall response rate among 35 evaluable patients was 54% (16 complete response (CR) and 3 complete response with incomplete hematologic recovery (CRi)). Ninety percent of responders achieved minimal residual disease (MRD) negativity (

Purpose: Treatment failure from drug resistance is the primary reason for relapse in acute lymphoblastic leukemia (ALL). Improving outcomes by targeting mechanisms of drug resistance is a potential solution. Patients and Methods: We report results investigating the epigenetic modulators decitabine and vorinostat with vincristine, dexamethasone, mitoxantrone, and PEG-asparaginase for pediatric patients with relapsed or refractory B-cell ALL (B-ALL). Twenty-three patients, median age 12 years (range, 1–21) were treated in this trial. Results: The most common grade 3–4 toxicities included hypokalemia (65%), anemia (78%), febrile neutropenia (57%), hypophosphatemia (43%), leukopenia (61%), hyperbilirubinemia (39%), thrombocytopenia (87%), neutropenia (91%), and hypocalcemia (39%). Three subjects experienced dose-limiting toxicities, which included cholestasis, steatosis, and hyperbilirubinemia (n = 1); seizure, somnolence, and delirium (n = 1); and pneumonitis, hypoxia, and hyperbilirubinemia (n = 1). Infectious complications were common with 17 of 23 (74%) subjects experiencing grade ≥3 infections including invasive fungal infections in 35% (8/23). Nine subjects (39%) achieved a complete response (CR + CR without platelet recovery + CR without neutrophil recovery) and five had stable disease (22%). Nine (39%) subjects were not evaluable for response, primarily due to treatment-related toxicities. Correlative pharmacodynamics demonstrated potent in vivo modulation of epigenetic marks, and modulation of biologic pathways associated with functional antileukemic effects. Conclusions: Despite encouraging response rates and pharmacodynamics, the combination of decitabine and vorinostat on this intensive chemotherapy backbone was determined not feasible in B-ALL due to the high incidence of significant infectious toxicities. This study is registered at http://www.clinicaltrials.gov as NCT01483690.

Introduction While 5-year event-free (EFS) and overall survival (OS) in Hodgkin lymphoma (HL) generally exceed 85% and 95%, respectively, outcomes may not be as favorable in adolescents and young adults (15 - 39 years [y]) compared to children. Small clinical trials have reported better outcomes for pediatric but not adult patients with mixed cellularity (MC) vs. nodular sclerosing (NS) histology, suggesting the possibility of biologic differences across the age-spectrum in HL. We examined survival by age and histology in patients receiving risk-based, response-adapted therapy for de novo HL on contemporary Children's Oncology Group (COG) trials. Methods This was a pooled analysis of individual-level data from 1,907 patients enrolled on three Phase 3 COG clinical trials for treatment of low-risk (AHOD0431), intermediate risk (AHOD0031) and high-risk (AHOD0831) HL between 2002 and 2012. Histologic subgroups included MC, NS and classical HL, not-otherwise-specified (cHL, NOS). Five-year cumulative incidence of relapse, EFS and OS were compared by age group ( Results Between 2002 and 2012, N= 2155 patients 1 - 21 y enrolled on three COG trials, 1,907 (88%) of whom were included in this analysis. Mean age of the cohort was 14.6 y (± 3.5) with N= 871 (46%) Survival: Median follow up was 6.9 years. In unadjusted analyses, 5-year EFS and OS were 83% and 97%, respectively. The 5-year EFS was lower for patients ≥15 y vs. The effect of age on EFS varied by histologic subgroup. Among those with non-MC histology, cumulative incidence of relapse did not significantly differ by age in unadjusted models (Figure A), however 5-year EFS was significantly worse in the older group (Figure B). In multivariable analyses, age ≥15 y (vs. younger) was associated with a 1.3-fold increased risk of EFS (HR: 1.3; 1.03 - 1.7, p= 0.03) (Table). Among patients with MC histology, age ≥15 y (vs. younger) was associated with significantly higher relapse rate (22% vs. 5%, p< 0.01) (Figure C) and significantly worse 5-year EFS (75% vs. 94%, p< 0.01) (Figure D). This remained significant in multivariable models: patients with MC histology who were ≥15 y (vs. younger) had a 3.7-fold increased risk of EFS (HR: 3.7, 95% CI: 1.6, 8.9, p< 0.01) (Table). Conclusion In patients receiving response-adapted therapy for de novo HL on contemporary COG trials, adolescents ≥15 y had worse EFS and OS compared to younger groups. The magnitude of the effect of age was higher in patients with MC disease. Although recent pediatric trials in HL have indicated better survival for some children with MC histology, alternative approaches or novel therapies should be considered for older adolescents with MC disease, whose outcomes appear more like adults. Disclosures No relevant conflicts of interest to declare.

Coagulation and bleeding assume particular importance when operations are performed on the heart using extracorporeal circulation. This chapter begins with a discussion of the depth and breadth of hemostasis relating to cardiac procedures, beginning with coagulation pathophysiology. The pharmacology of heparin and protamine is described next. This background is then applied to treatment of the bleeding patient.

YARS2 variants have previously been described in patients with myopathy, lactic acidosis and sideroblastic anemia 2 (MLASA2). YARS2 encodes the mitochondrial tyrosyl-tRNA synthetase, which is responsible for conjugating tyrosine to its cognate mt-tRNA for mitochondrial protein synthesis. Here we describe 14 individuals from 11 families presenting with sideroblastic anemia and YARS2 variants that we identified using a sideroblastic anemia gene panel or exome sequencing. The phenotype of these patients ranged from MLASA to isolated congenital sideroblastic anemia. As in previous cases, inter- and intra-familial phenotypic variability was observed, however, this report includes the first cases with isolated sideroblastic anemia and patients with biallelic YARS2 variants that have no clinically ascertainable phenotype. We identified ten novel YARS2 variants and three previously reported variants. In vitro amino-acylation assays of five novel missense variants showed that three had less effect on the catalytic activity of YARS2 than the most commonly reported variant, p.(Phe52Leu), associated with MLASA2, which may explain the milder phenotypes in patients with these variants. However, the other two missense variants had a more severe effect on YARS2 catalytic efficiency. Several patients carried the common YARS2 c.572 G>T, p.(Gly191Val) variant (minor allele frequency =0.1259) in trans with a rare deleterious YARS2 variant. We have previously shown that the p.(Gly191Val) variant reduces YARS2 catalytic activity. Consequently, we suggest that biallelic YARS2 variants, including severe loss-of-function alleles in trans of the common p.(Gly191Val) variant, should be considered as a cause of isolated congenital sideroblastic anemia, as well as the MLASA syndromic phenotype.

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Background: CPX-351 (Vyxeos®) is a liposomal nanoparticle of cytarabine and daunorubicin in a 5:1 molar ratio currently FDA approved for treatment of adults with newly-diagnosed therapy-related acute myeloid leukemia (AML) or AML with myelodysplasia-related changes. The agent also has potent activity against acute lymphoblastic leukemia (ALL) in murine xenograft models [H. Carol et al. Pediatr Blood Cancer 2015;62: 65-71]. We conducted the first phase I/pilot study to evaluate the safety and describe the efficacy of CPX-351 in children and adolescents with relapsed or refractory (R/R) acute leukemia (NCT01943682). Methods: In the Dose Exploration Phase participants age 12 months to 21 years were eligible to receive a single course of CPX-351 administered once daily on Days 1, 3, and 5. Enrollment was initiated at the recommended dose for study in adults (Dose Level 1: 100 Units/m2/dose= cytarabine 100 mg/m2 and daunorubicin 44 mg/m2 per dose) with provisions to explore either a single dose escalation to 134 Units/m2/dose (Dose Level 2) or de-escalation to 67 Units/m2/dose. Response was determined after Day 28. The upper age for eligibility was increased to 30 years and an additional 18 subjects were enrolled into the Expanded Phase of the study. Results: Nine children and adolescents with R/R AML (n=6) or ALL (n=3) were enrolled and evaluable for toxicity in the Dose Exploration Phase. All 9 experienced Grade 3 or 4 hematologic toxicity including 8 with fever with neutropenia or infection. Dose Limiting Toxicity (DLT) was not observed in the 4 patients enrolled at Level 1 but Grade 3 pain/headache lasting greater than 48 hours did occur in 2 of the 5 patients treated at Dose Level 2. One patient with AML was unevaluable for response in this phase due to removal from protocol therapy to receive bone marrow transplantation while in aplasia. All others were evaluable for response. One patient with ALL had stable disease, 2 with AML achieved a complete remission (CR), and 1 with AML achieved a CR in blood and marrow but developed low level disease in the cerebral spinal fluid (CSF). One patient with mixed phenotype acute leukemia and 17 with R/R AML were subsequently enrolled into the Expanded Phase of the study to receive CPX-351 at Dose Level 1. CPX-351 treatment was well tolerated in this population with a similar toxicity profile observed in the Dose Exploration Phase. Dose limiting prolonged aplasia occurred in one patient but no other DLTs were observed. The response has yet to be determined in one patient. To date, seven patients with AML (41%) achieved a CR or complete remission with incomplete blood recovery (CRi). Another patient achieved a CR in marrow but with low level disease detected in the CSF similar to the patient described in the Dose Exploration phase. The remaining 9 patients failed to achieve a clinical response. Pharmacokinetic (PK) parameters of total cytarabine and daunorubicin were analyzed for 21 of these pediatric patients and the results were similar to those observed in adults. However, due to the small sample size of each age group, these interim PK results will need to be validated as data in pediatric patients become available from future clinical studies. Conclusions: CPX-351 100 Units/m2/dose on Days 1, 3, and 5 was well tolerated in this pediatric population and has promising activity in children and young adults with R/R AML. Additional CNS directed therapy is recommended for pediatric patients at high risk for failure in the CNS. Disclosures Phillips: Novartis AG: Consultancy. An:Jazz Pharmaceuticals: Employment.

Objective To provide a comprehensive analysis of the temporal structure of sucking in full‐term neonates. Design Descriptive study. Setting Newborn nursery in a city teaching institution. Patients/Participants Fifty‐six full‐term infants with a mean birth weight of 3,128 ± 370g completed sucking assessments on the first and second day of life. Methods A 5‐minute sucking assessment was completed on the first and second day of life. Instruments included an Infant Nutritive Sucking Apparatus and the Anderson Behavioral Assessment Scale. Results The number of sucks (p Conclusion Our results show that sucking analysis is sensitive to infant status and suggest that the development of sucking methodology can be considered as a useful clinical tool to assess the normal developmental course of sucking patterns.

The relationship between the pattern of sucking behavior of preterm infants during the early weeks of life and neurodevelopmental outcomes during the first year of life was evaluated.The study sample consisted of 105 preterm infants (postmenstrual age [PMA] at birth = 30.5 +/- 2.8 weeks [mean +/- SD]; birth weight = 1476 +/- 460 g; mean length of hospital stay = 41.6 +/- 31.4 days). All infants received a 5-minute sucking test at 34 and at 40 weeks PMA, with outcomes evaluated at 6 and/or 12 months corrected gestational age via the Bayley Scales of Infant Development.As expected, 6- and 12-month values for the Psychomotor Developmental Index (PDI) and Mental Developmental Index (MDI) of the Bayley Scales of Infant Development were significantly below the normative levels established for infants delivered at term. A significant association between neonatal sucking pattern at 40 weeks PMA and developmental outcome at 12 months corrected gestational age was obtained. Each of the 3 simple sucking parameters evaluated (number of sucks, mean number of sucks per bursts and mean sucking pressure peaks), as well as a composite parameter (average of the respective parameter z-scores), was significantly related to both PDI and MDI at 12 months.Multivariable models, adjusting for PMA at birth, length of hospital stay, and other predictors, affirmed that sucking performance at 40 weeks PMA was a significant, independent predictor of developmental status 1 year later. Standardization of an instrument for neonatal sucking assessment may offer a cost-effective early screening strategy for preterm infants at greatest risk for developmental delay.

Ghrelin increases food intake when injected into either the forebrain or hindbrain ventricles. Brain areas activated by ghrelin after forebrain delivery have been examined using Fos immunohistochemistry and include the hypothalamic arcuate (Arc) and paraventricular (PVN) nuclei, and the nucleus of the solitary tract (NTS) in the medulla. It is not clear, however, if ghrelin applied directly to the hindbrain activates forebrain structures. Therefore, we examined Fos expression in the Arc, PVN, and NTS after injecting ghrelin into the fourth ventricle. Animals treated with a hyperphagic dose of ghrelin had greater levels of Fos expression in the NTS at the level of the area postrema than animals injected with vehicle. Ghrelin did not, however, increase Fos expression in the Arc or PVN in rats with open or occluded cerebral aqueducts. Given the importance of caudal brainstem (CBS) catecholamine pathways in the control of food intake, we performed double-labeling experiments to evaluate the potential overlap between tyrosine hydroxylase TH and ghrelin-induced Fos expression. Ghrelin did not increase Fos in TH-positive neurons in the NTS, suggesting that ghrelin delivered to the fourth ventricle does not act through catecholaminergic pathways. Nevertheless, the local (NTS), but not distal (Arc and PVN), induction of Fos suggests the presence of partially independent forebrain and hindbrain circuits that respond to ghrelin. These data support the NTS as a target of ghrelin action by building upon prior findings of increases in food intake in response to third- and fourth-ventricle ghrelin delivery.

The elevation of plasma ghrelin associated with weight loss has been taken as evidence of a role for ghrelin in the adaptive response to body weight change. However, there has been no clear experimental evidence that circulating ghrelin is suppressed by weight gain. We investigate this issue using a model of involuntary (intra-gastric gavage) overfeeding-induced obesity. Rats were first maintained at normal body weight with 4 daily tube-feedings of liquid diet (2.11 kcal/ml), each delivered at a volume of 9 ml. Gavage volume was then increased to 13 ml/feeding for 2 weeks, during which rats gained 25% of their initial body weight. Fasting plasma ghrelin levels and the response to 9- and 13-ml intra-gastric load sizes were measured during the weight-stable and overfed conditions. We found that: 1) weight gain decreased circulating ghrelin levels; 2) this response could not be attributed to additional food in the gastrointestinal tract; 3) the ghrelin response to nutrient loads was diminished in the obese vs normal-weight conditions. Having discounted diet composition and differences in gastric contents at the time of blood sampling, the decrease in ghrelin levels with overfeeding can be unambiguously attributed to physiological correlates of weight gain.

The orexigenic hormone ghrelin is implicated in preprandial hunger and meal initiation in part because circulating levels increase before meals and decrease after food intake. The mechanisms underlying postprandial ghrelin suppression are unknown. Although most ghrelin is produced by the stomach, we have shown that neither gastric nutrients nor gastric distension affect ghrelin levels. We hypothesized that the nutrient-sensing mechanism regulating ghrelin is in the duodenum, the second richest source of ghrelin. To test whether duodenal nutrient exposure is required for ghrelin suppression, we infused nutrients into either the proximal duodenum or proximal jejunum in rats bearing chronic intestinal cannulas. At 0, 30, 60, 90, 120, 180, 240, and 300 min after infusions, blood was sampled via jugular-vein catheters for ghrelin, insulin, and glucose measurements. To elucidate further the mechanisms governing nutrient-related ghrelin suppression, we also assessed the ghrelin responses to isocaloric (3 kcal) infusions of glucose, amino acids, or lipids delivered into the stomach or small intestine of chronically catheterized rats. Regardless of macronutrient type, the depth and duration of ghrelin suppression were equivalent after gastric, duodenal, and jejunal infusions. Glucose and amino acids suppressed ghrelin more rapidly and strongly (by approximately 70%) than did lipids (by approximately 50%). Because jejunal nutrient infusions suppressed ghrelin levels as well as either gastric or duodenal infusions, we conclude that the inhibitory signals mediating postprandial ghrelin suppression are not derived discretely from either the stomach or duodenum. The relatively weak suppression of ghrelin by lipids compared with glucose or amino acids could represent one mechanism promoting high-fat dietary weight gain.

The multiple-day hyperphagic effect of the melanocortin 3/4 receptor antagonist, SHU9119, is apparently abolished when rats are food-deprived for 24 h after central (4th-ventricular) injection. Here, we affirmed this indication, and addressed the possibility that the orexigenic potency of SHU9119 is simply masked by the refeeding hyperphagia that follows food deprivation. This explanation is discounted by our finding that the drug response in ad libitum-fed rats and the deprivation response are expressed at different, and non-overlapping, times of day. We then asked whether food consumption during a hypothesized critical period in the hours after treatment is necessary for expression of the hyperphagic response to SHU9119, or alternatively, whether blood-borne signals that emerge only after an extended period of food restriction underlie the drug-state interaction. Evidence favoring the latter interpretation was derived from a series of four experiments over which the timing and duration of food access after drug administration was varied. The results indicate an interaction between melanocortin receptor activity and the metabolic state of the animal, and constrain our thinking about the peripheral signals and central mechanisms that underlie this interaction.

Central administration of melanocortin 3 and 4 receptor (MC3/ 4-R) agonists increases energy expenditure, with the hypothalamus commonly held as the primary site of action. It is also clear, however, that MC4-R are expressed in caudal brainstem structures of relevance to the control of energy expenditure. Three experiments investigated whether hindbrain MC-R contribute to the energy expenditure effects of central MC3/4-R agonist treatments; in each, we examined the effect of fourth intracerebroventricular (icv) administration of a MC3/4-R agonist, MTII (three injections, each separated by 12 h), on uncoupling protein 1 (UCP-1) gene expression in brown adipose tissue (BAT). First, we compared the effects of fourth and third icv administration of MTII and found that the hindbrain and forebrain treatments were equally effective at elevating UCP-1 mRNA expression in BAT compared with the respective vehicletreated group results. A second experiment demonstrated that the fourth icv MTII-induced rise in UCP-1 expression was mediated by sympathetic outflow to BAT by showing that this response was abolished by surgical denervation of BAT. In the third experiment, we showed that chronic decerebrate rats, like their neurologically intact controls, elevated UCP-1 mRNA expression in response to fourth icv MTII administration. Taken together, the results indicate that: 1) there is an independent caudal brainstem MC3/4-R trigger for a sympathetically stimulated elevation in BAT UCP-1 gene expression, and 2) the MTIIinduced rise in UCP-1 expression can be mediated by circuitry intrinsic to the caudal brainstem and spinal cord. (Endocrinology 144: 4692–4697, 2003)

The role of ghrelin in feeding control has been addressed from a largely hypothalamic perspective, with little attention directed at ingestive consequences of stimulation of the peptide’s receptor, the growth hormone secretagogue receptor (GHS-R), in the caudal brainstem. Here, we demonstrate a hyperphagic response to stimulation of GHS-R in the caudal brainstem. Ghrelin (150 pmol) delivered to the third and fourth ventricles significantly and comparably increased cumulative food intake, with maximal response ∼3 h after injection. The meal patterning effects underlying this hyperphagia were also similar for the two placements (i.e., significant reduction in the time between injection and first-meal onset, an increase in the number of meals taken shortly after the injection, and a trend toward an increase in the average size of the first meals that approached but did not achieve statistical significance). In a separate experiment, ghrelin microinjected unilaterally into the dorsal vagal complex (DVC) significantly increased food intake measured 1.5 and 3 h after treatment. The response was obtained with a 10-pmol dose, establishing the DVC as a site of action with at least comparable sensitivity to that reported for the arcuate nucleus. Taken together, the results affirm a caudal brainstem site of action and recommend further investigation into multisite interactions underlying the modulation of ingestive behavior by ghrelin.

The hypothalamic feeding-center model, articulated in the 1950s, held that the hypothalamus contains the interoceptors sensitive to blood-borne correlates of available or stored fuels as well as the integrative substrates that process metabolic and visceral afferent signals and issue commands to brainstem mechanisms for the production of ingestive behavior. A number of findings reviewed here, however, indicate that sensory and integrative functions are distributed across a central control axis that includes critical substrates in the basal forebrain as well as in the caudal brainstem. First, the interoceptors relevant to energy balance are distributed more widely than had been previously thought, with a prominent brainstem complement of leptin and insulin receptors, glucose-sensing mechanisms, and neuropeptide mediators. The physiological relevance of this multiple representation is suggested by the demonstration that similar behavioral effects can be obtained independently by stimulation of respective forebrain and brainstem subpopulations of the same receptor types (e.g., leptin, CRH, and melanocortin). The classical hypothalamic model is also challenged by the integrative achievements of the chronically maintained, supracollicular decerebrate rat. Decerebrate and neurologically intact rats show similar discriminative responses to taste stimuli and are similarly sensitive to intake-inhibitory feedback from the gut. Thus, the caudal brainstem, in neural isolation from forebrain influence, is sufficient to mediate ingestive responses to a range of visceral afferent signals. The decerebrate rat, however, does not show a hyperphagic response to food deprivation, suggesting that interactions between forebrain and brainstem are necessary for the behavioral response to systemic/ metabolic correlates of deprivation in the neurologically intact rat. At the same time, however, there is evidence suggesting that hypothalamic-neuroendocrine responses to fasting depend on pathways ascending from brainstem. Results reviewed are consistent with a distributionist (as opposed to hierarchical) model for the control of energy balance that emphasizes: (i) control mechanisms endemic to hypothalamus and brainstem that drive their unique effector systems on the basis of local interoceptive, and in the brainstem case, visceral, afferent inputs and (ii) a set of uni- and bidirectional interactions that coordinate adaptive neuroendocrine, autonomic, and behavioral responses to changes in metabolic status.

In the present study, we provide a cross-sectional analysis of sucking organization as a function of gestational age (GA). One hundred and eighty six infants (GA 33–40 weeks) were observed during 5-min test sessions with the Kron Nutritive Sucking Apparatus either on the second day (GA 35–40), or as soon as was practicable during the first week (GA 33 and 34) of life. The within-burst suck frequency did not vary with GA suggesting that this basic aspect of patterned sucking behavior was already in place in the most premature infants. For four sucking parameters (number of sucks per session, duration of sucking bursts, burst time as percentage of sucking bout, and mean maximum sucking pressure) that varied with GA, the transitions were not seen across the earliest GAs, but rather occurred between 36/37 and full term (38–42 weeks GA). An earlier transition (GA33/34) was suggested for the coefficient of variation (CV) for the distribution of within-burst intersuck intervals and for the CV of the maximum sucking pressure distribution. Significant changes were described over bout quintiles for several parameters, but there were no meaningful interactions between GA and the manner by which sucking changes as meals progress. Our results suggest that different aspects of the sucking pattern mature at different GAs, and are of relevance to discussions of neurobehavioral development.

The volume of fluid that rats acquire with each lick was systematically varied across short-term tests with 12.5% glucose (Experiment 1) or 12.5% maltodextrin (Experiment 2). For glucose, rats increased the number of licks emitted as lick volume was reduced such that meal size remained remarkably stable across all (8, 4, and 2 microl) but the smallest (1 microl) lick volume conditions tested. Rats similarly compensated for lick volume reduction (8 to 4 microl) with maltodextrin by approximately doubling the number of licks emitted. Meal duration and a number of lick-microstructural parameters (initial ingestion rate, mean burst duration, terminal lick and ingestion rates, and burst duration) were not correlated with the intake outcome insofar as they varied significantly across conditions over which intake remained stable. Thus, in response to lick volume manipulation, rats demonstrated an impressive degree of behavioral flexibility in what may be regarded as a defense of meal size.

Fourth intracerebroventricular (4th-icv) administration of the melanocortin-3/4 receptor (MC3/4-R) agonist, MTII, reduces food intake; the antagonist, SHU9119, increases feeding. The dorsal motor nucleus of the vagus nerve (DMX) contains the highest density of MC4-R messenger RNA in the brain. To explore the possibility that the DMX contributes to 4th-icv MC4-R effects, we delivered doses of MTII and SHU9119 that are subthreshold for ventricular response unilaterally through a cannula centered above the DMX. MTII markedly suppressed 2-h (50%), 4-h (50%), and 24-h (33%) intake. Feeding was significantly increased 4 h (50%) and 24 h (20%) after SHU9119 injections. These results suggest that receptors in the DMX, or the dorsal vagal complex more generally, underlie effects obtained with 4th-icv administration of these ligands. We investigated possible vagal mediation of 4th-icv MTII effects by giving the agonist to rats with subdiaphragmatic vagotomy. MTII suppressed 2-, 4-, and 24-h liquid diet intake (∼80%) to the same extent in vagotomized and surgical control rats. We conclude that stimulation or antagonism of MC3/4-Rs in the dorsal vagal complex yields effects on food intake that do not require an intact vagus nerve.

The effect of the somatostatin analog agonist octreotide (Oct) on gastric emptying of 12.5% glucose during and after intragastric fill was examined in nondeprived rats equipped with stainless steel gastric fistulas. The rate of intragastric infusion (1.0 ml/min) and the volumes delivered (6 or 12 ml) were within the ranges typically observed in rats normally ingesting the same stimulus. In experiment 1, a dose-related suppression of glucose emptying during 12-min infusions was obtained in response to Oct (0, 0.0014, 0.014, 0.14, and 1.4 nmol/kg sc) injected 60 min before the test. The highest dose tested yielded a 37% suppression of glucose solute emptying during fill. In experiment 2, the suppression of emptying during fill induced by Oct (1.4 nmol/kg) was reversed by 10 or 40 μg/kg of the somatostatin antagonist cyclo(7-aminoheptanoyl-Phe-d-Trp-Lys-Thr[Bzl]). The antagonist did not by itself affect emptying. Experiment 3 showed that the suppression of emptying obtained with 0.14 and 1.4 nmol/kg Oct had disappeared when the gastric sample was withdrawn 36 min after the termination of 12-min glucose infusions. Experiment 4 showed that the Oct-induced reductions in emptying during 6- and 12-min infusions, in fact, were reversed within 6 min after infusion offset. The point of transition between suppressed and increased emptying did not depend on time from injection or from infusion onset but was linked to the offset of the intragastric infusion regardless of its duration. The present findings support the notion that separable mechanisms govern gastric emptying during vs. after gastric fill.

Oscar Wilde was punished not for failing to amuse the high society audiences for which he wrote, but for offending that society's sexual attitudes. Ironically, as Joel Kaplan and Sheila Stowell point out, his death transformed him ‘from a criminal outcast to a figure both redeemed and bankable’. For those who wished to exploit his theatrical legacy, the problems arose first of sufficiently dissociating the plays from what was perceived as their author's irredeemable behaviour – and then of finding a theatrical language to make the ridiculing of Victorian virtues risible for a society which had settled into the more relaxed moral corsetry of the Edwardians. Here, the authors take two contrasting cases in which audience reaction was decisive – the failure in 1913 of the attempt to dramatize Wilde's novel,The Picture of Dorian Gray, by converting it into a moral tract; and the process by whichThe Importance of Being Earnest, after a few attempts to render it timeless, became firmly pinned down in its period – and so a play at which audiences could safely laugh, confident they were no longer themselves the butts of the jokes. Joel Kaplan is Professor of Drama and Theatre Arts at the University of Birmingham. His recent publications include (with Sheila Stowell)Theatre and Fashion: Oscar Wilde to the Suffragettesand (edited with Michael Booth)The Edwardian Theatre: Essays on Performance and the Stage. Sheila Stowell is Senior Research Fellow in Drama at the University of Birmingham, and the author ofA Stage of Their Own: Feminist Playwrights of the Suffrage Era.

The effects of hepatic-portal glucose or saline infusions on intake and the temporal distribution of licking (lick microstructure) were evaluated in nondeprived and in 20.5-h food-deprived rats. Rats received portal infusions of isotonic glucose or saline (0.1 ml/min) for 2 h before and then throughout a 90-min period of access to a spout that delivered 12.5% glucose. Overall, a significant treatment-related intake suppression was obtained in nondeprived but not in deprived groups. For both groups, however, there was a significant positive linear relationship between the amount individual rats consumed under the saline (baseline) infusion condition and the extent to which portal glucose infusion suppressed intake. The linear fit for the deprived group was similar in slope, but right shifted, relative to the best fit for the nondeprived group. The individual-subject and group differences in response to portal glucose infusion are discussed in relation to the inconsistent literature on this treatment’s short-term intake effects. We focused analysis of the licking pattern on those rats for which a prominent portal glucose infusion effect was obtained (i.e., nondeprived rats with higher than average baseline intakes). Features of the lick pattern associated with taste evaluation (1st min lick rate; lick burst duration) were not significantly affected by portal glucose infusion. Rather, the minute-by-minute rate of ingestion under glucose infusion declined more rapidly than under baseline tests, indicating that portal glucose infusion enhanced the inhibitory influence of the accumulating postingestive load.

Injection of the fructose analogue, 2,5-anhydro-d-mannitol (2,5-AM), increases food intake and Fos-like immunoreactivity (Fos-li) in both brainstem and forebrain structures. Because of the interconnections between brainstem and forebrain areas, it has not been possible to determine whether or to what extent induction of Fos-li in a given region reflects brainstem-forebrain interactions. We addressed this issue using chronic decerebrate (CD) rats with complete transections of the neuroaxis at the meso-diencephalic juncture. CD and neurologically intact control rats were injected (i.p.) with saline or 400 mg/kg 2,5-AM and brains were examined for Fos-li. Both intact and CD rats showed increased Fos-li in the nucleus of the solitary tract (NTS) after injection of 2,5-AM as compared with saline. 2, 5-AM treatment increased Fos-li in the external lateral division of parabrachial nucleus (PBNel) in intact but not in CD rats, suggesting that descending projections from the forebrain may play a role in the activation of PBNel neurons after 2,5-AM injection. Decerebration eliminated significant 2,5-AM-induced Fos-li responses in forebrain structures, including the paraventricular nucleus, supraoptic nucleus, bed nucleus of the stria terminalis and central nucleus of the amygdala. The results are consistent with the hypothesis that the activation of forebrain structures after 2,5-AM treatment is due to stimulation by ascending projections from the brainstem.

The role of caudal brainstem 5-HT receptors in mediating the anorectic effect of the direct 5-HT2C/1B agonist, mCPP [1-(3-chlorophenyl)piperazine dihydrochloride], was evaluated. We demonstrated, first, that systemic injections of mCPP yielded a dose-related suppression of intra-oral intake of 12.5% glucose in intact rats and in chronically maintained supracollicular decerebrate rats. The results of the decerebrate experiment suggest that 5-HT receptors in the caudal brainstem are sufficient for mediating the drug's intake effect. We also showed a dose-related intake suppression when mCPP was delivered to the fourth ventricle of intact rats, with potent suppression obtained at doses well below threshold for systemic administration. Whether and to what extent the 5-HT2C/2A antagonist, mesulergine reverses the intake suppression that follows systemic or 4th i.c.v. injection of mCPP was examined. Fourth i.c.v. co-administration of mesulergine (60 microg) and mCPP (40 microg) eliminated the approximately 50% intake suppression observed when mCPP was delivered alone, a result that affirms the receptor selectivity of the 4th i.c.v. agonist effect. We showed, further, that 4th i.c.v.mesulergine (60 microg) completely reversed the intake suppression produced by systemic mCPP (2 mg/kg). The latter result indicates that stimulation of 5-HT receptors in the caudal brainstem is necessary for the intake suppression produced by systemic administration of this 5-HT agonist in the intact rat.

The simultaneous contrast paradigm was used to evaluate responsiveness to a low (0.05 M) and a high (0.5 M) concentration of sucrose under two conditions in intact and chronic decerebrate rats. In one condition the low concentration was presented on one day and the high concentration on another. In the other condition presentation of the two concentration was alternated within the same daily session. In each case there was a total of 40 trials/day during which the stimulus was delivered intraorally for 2 s at a rate of 1.5 ml/min with a 30-s intertrial interval. The results showed that the intact rats always licked more for the high than for the low concentration of sucrose but that the magnitude of the effect was larger when given the opportunity to compare the two concentrations within the same daily session. The decerebrate rats produced a similar pattern, but the concentration effect was evident only when the stimuli were alternated within the same daily session. These data stand as the first evidence that the isolated caudal brain stem is adequate for the expression of a behavior that depends on comparison processes involving short-term memory.

We evaluated the effects of lateral intracerebroventricular administration of oxytocin (OT) and/or a selective oxytocin-receptor antagonist (OTX), 1-deamino-2-D-Tyr-(OEt)-4-Thr-8-Orn-OT, on ingestion of intraorally delivered 12.5% glucose in rats that were either nondeprived or deprived of food for 20 h. In deprived rats, OT delivered 30 min before an initial intake test yielded a dose-related reduction of intraoral glucose intake. The highest dose tested, 20 nmol, reduced intraoral glucose intake by 45%. The effect was short-lived, however. Intraoral intake for a second test, initiated 60 min after the termination of the first, increased as a function of OT dose so that total session intake was unaffected by OT treatment. The suppression of intraoral intake by 20 nmol OT was reversed by pretreatment (45 min before testing) with OTX. In nondeprived rats, by contrast, OT yielded no effect on first-test, second-test, or total session intakes. Significant increases in first-test and total session intakes were obtained when OTX (20 nmol) was administered alone both in deprived (32% increase in first-test intake) and nondeprived (31% increase) rats. In general, the results obtained are consistent with the suggestion that OT contributes to the control of meal size and, in particular, to the process of satiation, which is the aspect of ingestive control highlighted by the specialized intake test used in the present study.

The effects of hepatic portal infusions of isotonic glucose on glucose intake (3.2%) were evaluated with use of the intraoral intake test, which, unlike traditional tests, permits delivery of portal infusions in explicit temporal relationship to intake onset in nondeprived rats. Continuous or discontinuous portal infusions (0.1 ml/min) of isotonic glucose or saline were initiated 0, 30, 60, or 120 min before meal onset. Jugular infusions of isotonic saline or glucose and portal infusions of isotonic saline were without effect. For all effective portal glucose infusions, intake was suppressed by approximately 30% of baseline values. Because the duration (and quantity) of effective portal glucose infusions varied by a factor of 10, we conclude that intraoral intake suppression under these conditions is all or none in nature. Whether an intake suppression was obtained depended more on when the infusion was delivered than on how much was infused. Thus 1.5 ml of isotonic glucose infused between 60 and 45 min before the intake test was effective, whereas 3.0 ml infused for the 30 min before intake was without effect. These results suggest that the liver participates in the control of future intake but not in the termination of an ongoing meal. The temporal requirement for intake suppression should be considered in analyses of the metabolic, hormonal, and/or neural mechanisms that underlie the liver's contribution to intake control.

In the present study, we ask whether the suppressive effect of d-fenfluramine ( d-FEN) on short-term intake can be better explained in terms of a primary action on particular behavioral parameters (e.g., ingestion rate or meal duration), as proposed by several investigators, or in terms of a primary effect on an intake “target” that can be achieved via diverse behavioral strategies. We applied two specialized intake testing paradigms that constrain the behavioral structure of the rat's meal in different ways, and determined whether or not the meal-size result varied in turn. [1] In the intraoral intake test, the rate of ingestion was clamped by the rate (1.0 ml/min) at which the test stimulus (12.5 % glucose) was intraorally delivered. A d-FEN (3 mg/kg) suppression of intraoral intake was obtained demonstrating that ingestion rate adjustment is not necessary for the anorexic effect. In addition, for both d-FEN and vehicle conditions, comparable amounts were consumed when the intraoral intake test was either continuous or interrupted for 10 min beginning 6 min after test onset. For d-FEN, the increase in meal duration (mean = 11.98 min) required to compensate for the imposed interruption indicates that the drug does not specify an absolute limit for meal duration. [2] In the drop size-controlled spout-licking test, the volume of 12.5% glucose delivered for each lick was fixed at either 8 or 4 μl. There was an overall reduction in intake with d-FEN (0.75 mg/kg), but as under vehicle injection conditions, the number of licks emitted approximately doubled when lick volume was halved. As a result, meal size was unaffected by the drop size manipulation. The drop size manipulation affected several other behavioral parameters under respective d-FEN and vehicle injection conditions, including: average rate of ingestion (ml/min), initial ingestion rate, and ingestion duration (meal duration minus pause time). The two experiments together demonstrate that the anorexic effect of d-FEN does not depend on adjustment of any particular behavioral parameter. The results suggest, rather, that given doses of d-FEN establish a particular degree of intake suppression that the rat defends via diverse behavioral strategies.

Of the central 5-HT substrates that may mediate the anorexic actions of systemically administered d-fenfluramine (d-FEN), those in the forebrain have received the most attention. As a counterpoint to this forebrain focus, we evaluated the contribution of caudal brainstem substrates to the anorexic action of d-FEN. Two experimental protocols were employed. In one we compared the feeding response (intra-oral intake of 12.5% glucose) of intact and chronic supracollicular decerebrate (CD) rats to systemic administration of d-FEN. In the other, d-FEN was administered via fourth intracerebroventricular (ICV) injection to determine whether a dose-related suppression of intra-oral intake could be obtained. A dose-dependent suppression of intra-oral intake was obtained in the CD rat treated with d-FEN (0-8 mg/kg, delivered IP 20 min before testing). The threshold dose was two to three times higher in CD rats than in their intact controls, but the dynamic range of the dose-response curves of the two groups were overlapping with similar slopes of decline and with comparable maximal intake suppression. Fourth ICV administration of d-FEN in the intact rat yielded a dose-related suppression of intra-oral intake. Intake was also suppressed by fourth ICV d-FEN (30 mg) when rats drank 12.5% glucose solution from a spout. The reduced intra-oral intake following fourth ICV d-FEN treatment was partially attenuated by the systemic administration of the serotonin antagonist metergoline (0.4 mg/kg; IP). The CD results demonstrate the sufficiency of caudal brainstem receptors in mediating intake suppressive responses to systemic d-FEN. The fourth ICV results suggest further that 5-HT receptors in the caudal brainstem play a significant role in normal meal size control in the neurologically intact rat.

In ingestive taste reactivity analysis, the rhythmic oral motor responses observed during intraoral infusion of fluids normally ingested by rats are categorized and counted. These rhythmic movements can be likened to spout-licking in several respects. Both are emitted in the same frequency range (5–8 Hz), organized in a burst/pause pattern, and serve the function of intraoral transport of fluid into position for swallowing. The parallel suggests that a temporal pattern analysis, based on the spout-licking literature, can be fruitfully applied to the rhythmic movements that attend intraoral infusion. We provide a demonstration of such an analysis using an electromyographic (EMG) recording-based method for automated event detection. Eight rats received a 37.5% glucose solution (1.0 ml/min) in a series of 120 s infusion trials (45 s intertrial intervals) that was extended until the fluid was rejected. Movement counts declined 19.1% from the first to the last complete trial. Parameters derived from the pattern analysis (number of bursts, mean burst duration, pause durations, coefficient of variation for the distribution of within-burst intermovement intervals) were affected to a greater extent. The results indicate the potential value of temporal pattern analysis for various applications of the taste reactivity paradigm.

Plasma ghrelin levels are rapidly suppressed by ingestion or gastric delivery of nutrients. Given that the majority of circulating ghrelin appears to be of gastric origin, we addressed the contribution of gastric distention or nutrient sensitivity to this response. Awake, unrestrained rats received intragastric infusions of glucose or water (1 ml/min for 12 min) with gastric emptying either proceeding normally or prevented by inflation of a pyloric cuff. When emptying was permitted, glucose infusion reduced ghrelin level by approximately 50%, and, in agreement with previous data, water infusions were without effect. Ghrelin level was not affected by either infusate when gastric emptying was prevented, thereby discounting a role for gastric distention in the meal-related ghrelin response. That glucose and water infusions were similarly ineffective when the pylorus was occluded shows, further, that gastric chemosensation is not a sufficient trigger for the ghrelin response. We conclude that the meal-related suppression of plasma ghrelin requires postgastric (pre- or postabsorptive) stimulation.

The notion that satiation signals are derived from the stomach with no additional contribution of postgastric sources (J. A. Deutsch. In: Handbook of Behavioral Neuroscience. Food and Water Intake. 1990, vol. 10, p. 151–182) was evaluated in two experiments. In experiment 1, the gastric contents were withdrawn after the rat met the satiety criterion for an initial intraoral intake test (12.5% glucose delivered at 1.0 ml/min). Ten minutes later, the intraoral infusion was continued until the rat again met the satiety criterion. We found that rats reingested an amount closely corresponding to the amount withdrawn, in agreement with previous studies using spout-licking tests. Despite a lower gastric emptying rate during reingestion than during the initial test, the amount recovered from the stomach (both volume and solute content) after reingestion was significantly less (gastric volume 16% less; gastric glucose 18% less) than that withdrawn initially. In experiment 2, a portion (8 ml) of the gastric contents was removed after the end of an initial intraoral intake test and, after 10 min, rats were again given an opportunity to ingest to satiety. The procedure was repeated for a total of three withdrawals (24 ml) and three reingestion opportunities. Rats accurately replaced the amounts withdrawn such that net intake at the end of the experiment did not differ from that ingested during the initial test. In addition, the amount recovered from the stomach after the terminal test was considerably less (gastric volume 25% less; gastric glucose 29% less) than that recovered at the end of single-test control sessions. Both experiments show that gastric feedback cannot alone account for the termination of intraoral intake. The results suggest that rats defend total intake and do so via the integration of signals derived from postgastric as well as gastric sources. stomach; satiation Submitted on November 15, 1993 Accepted on May 12, 1994

Philip Prowse (b. 1937) is something of an anomaly in contemporary British theatre, a director who comes to his craft from a design rather than a performance background. Trained at London's Slade School of Art, Prowse worked briefly in the model rooms at Covent Garden before becoming stage designer at the Watford Palace in 1967. Two years later he moved on to the Glasgow Citizens Theatre, where he has continued to serve as part of the triumvirate (together with Giles Havergal and Robert David MacDonald) responsible for that company's artistic direction. Over the past two decades Prowse's aesthetic has come to dominate the Citizens, helping to make it unique among Britain's regional troupes, both in its European outlook and in its sumptuous, exuberant theatricality. Through the period Oscar Wilde has been a mainstay of the company's repertoire. In the 1970S Prowse twice designed Havergal's stagings of The Importance of Being Earnest, including a 1977 mounting of the play's four-act version. During the following decade he both directed and designed his own productions of all three of Wilde's society plays, A Woman of No Importance (1984), An Ideal Husband (1986), and Lady Windermere's Fan (1988), claiming to have found them "comedies" and left them "dramas." The accomplishment — regarded by critic Michael Coveney as "the glory of Prowse's work ... in the 1980s" — has led the Guardian's Michael Billington to credit Prowse with "completely revis[ing] our notion of how to play early Oscar" (9 May 1988). In 1991 Prowse made his Royal Shakespeare Company debut with a new production of A Woman of No Importance. Much indebted to his Citizens' staging, it played to full houses at the Barbican, before transferring to the Haymarket for an extended West End run. The following interview was conducted in Prowse's London flat, shortly after the Glasgow opening of his 1993 adaptation of The Picture of Dorian Gray.