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Purpose:Kaposi sarcoma (KS), an endothelial cell tumor associated with KS herpesvirus (KSHV), remains among the most common malignancies occurring with HIV infection (HIV-KS). As an oral anti-inflammatory, antiangiogenic, and immunomodulatory agent, lenalidomide is potentially an attractive alternative to standard chemotherapy for KS.Experimental Design:The primary objectives of this phase I/II trial were to determine the maximum tolerated dose (MTD) and response rates for lenalidomide in HIV-KS. Secondary objectives included correlating response with natural killer (NK) and T-cell subsets, plasma cytokines, viral copy number, and KSHV gene expression in biopsies. Four dose levels of oral lenalidomide taken 21 consecutive days of 28-day cycles were evaluated in adults with HIV-KS on antiretroviral therapy with controlled viremia.Results:Fifteen and 23 participants enrolled in phases I and II, respectively, 76% of whom had received prior KS therapy. The MTD was not reached, declaring 25 mg as the recommended phase II dose (RP2D). The most frequent adverse events were neutropenia, fatigue, leukopenia, and diarrhea. Of the 25 evaluable participants receiving RP2D, 60% responded. Correlative studies performed in a subset of participants demonstrated a significant increase in proportions of blood T cells with T-regulatory phenotype, and plasma cytokines trended toward a less inflammatory pattern. Clinical response was associated with loss of KSHV transcription.Conclusions:Lenalidomide is active in HIV-KS. The most common adverse events were manageable. With 60% of participants receiving RP2D obtaining a partial response and See related commentary by Henry and Maki, p. 2485

Supplementary Data from AMC-070: Lenalidomide Is Safe and Effective in HIV-Associated Kaposi Sarcoma

Purpose:Kaposi sarcoma (KS), an endothelial cell tumor associated with KS herpesvirus (KSHV), remains among the most common malignancies occurring with HIV infection (HIV-KS). As an oral anti-inflammatory, antiangiogenic, and immunomodulatory agent, lenalidomide is potentially an attractive alternative to standard chemotherapy for KS.Experimental Design:The primary objectives of this phase I/II trial were to determine the maximum tolerated dose (MTD) and response rates for lenalidomide in HIV-KS. Secondary objectives included correlating response with natural killer (NK) and T-cell subsets, plasma cytokines, viral copy number, and KSHV gene expression in biopsies. Four dose levels of oral lenalidomide taken 21 consecutive days of 28-day cycles were evaluated in adults with HIV-KS on antiretroviral therapy with controlled viremia.Results:Fifteen and 23 participants enrolled in phases I and II, respectively, 76% of whom had received prior KS therapy. The MTD was not reached, declaring 25 mg as the recommended phase II dose (RP2D). The most frequent adverse events were neutropenia, fatigue, leukopenia, and diarrhea. Of the 25 evaluable participants receiving RP2D, 60% responded. Correlative studies performed in a subset of participants demonstrated a significant increase in proportions of blood T cells with T-regulatory phenotype, and plasma cytokines trended toward a less inflammatory pattern. Clinical response was associated with loss of KSHV transcription.Conclusions:Lenalidomide is active in HIV-KS. The most common adverse events were manageable. With 60% of participants receiving RP2D obtaining a partial response and See related commentary by Henry and Maki, p. 2485

Promoting healthy behavior among seniors is important in reducing the burden of care and healthcare expenses in a rapidly aging society. Health apps can play an important role in health promotion for older adults, but the level of user retention in health apps is low. To increase continued health app use among older adults, this study examined the factors influencing older users’ continuance intentions to use health apps. The research model was developed based on the social cognitive theory of health behavior, which integrates cognitive, environmental, and behavioral perspectives. To test the research model, an anonymous online survey was conducted among respondents aged 60 to 79 years who were using health apps. The measurement items in the questionnaire were developed based on validated scales from the literature. A total of 250 samples were analyzed. The assessment of the measurement model indicates that the reliability and validity of the items are satisfactory. The results of testing the structural model illustrate the determinants of health app continuance intention: health technology self-efficacy, self-evaluative outcome expectations, self-regulation, and privacy risk. The interrelationships among determinants are also investigated. Theoretical and practical implications are suggested to encourage older adults’ continued health app use and promote their health behavior over the long term.

Background Klebsiella pneumoniae brain abscesses are a rare entity and typically present in immunocompromised patients. We present a case of an overall healthy patient who developed a Klebsiella pneumoniae brain abscess in the absence of liver pathology. Case presentation A 46-year-old Vietnamese man with past medical history significant for hypertension presented to the hospital with acute on chronic worsening of altered mental status, personality changes, and gait dysfunction. Initial vitals revealed temperature of 37.1 °C, heart rate 87 beats/minute, blood pressure 150/87 mmHg, respiratory rate 18/minute, and oxygen saturation 99% on room air. Physical exam was notable for altered mental status, Glasgow Coma Scale (GCS) score of 14, and right lower facial droop. Cardiopulmonary exam was within normal limits. Head computed tomography (CT) showed a left frontotemporal mass, with subsequent brain magnetic resonance imaging (MRI) revealing a ring-enhancing lesion concerning for a brain abscess. The abscess was urgently drained; however, there was intraoperative spillage into the ventricles. Intraoperative cultures grew Klebsiella pneumoniae, and the patient was maintained on appropriate antibiotics. He developed worsening mental status, septic shock, and cerebral edema requiring decompressive left hemicraniectomy. Computed tomography of the abdomen and pelvis revealed no hepatic lesions. The patient did not improve, and the family elected for comfort measures. Conclusion High mortality is associated with Klebsiella pneumoniae (as opposed to Klebsiella oxytoca) brain abscesses, especially in the setting of intraventricular spread. This case illustrates the need for early detection, and an aggressive medical and surgical treatment approach is required for a potential favorable outcome.

Background: Novel coronavirus infection (SARS CoV-2 or COVID-19) is associated with a high risk of thrombotic complications, including macro- and micro-thrombi in major organs, leading to increased morbidity and mortality. Anticoagulant use, mainly heparin, which has both anticoagulant and anti-inflammatory properties, has been suggested as potentially beneficial. However, the optimal dose of anticoagulant for patients with COVID-19 is unknown. Establishing the optimal thromboprophylaxis strategy and determining the role of biomarkers for patient risk stratification may help to improve outcomes in COVID-19. Methods: This single-center retrospective cohort study is part of an ongoing Quality Improvement project on the use of an anti-factor Xa-driven heparin protocol, which includes a low-dose intravenous (IV) unfractionated heparin (UFH) option, being conducted at our medical center. Data on the type, dose, and indication for anticoagulation as well as outcomes including thrombosis, bleeding and survival was collected for inpatients diagnosed with COVID-19 between mid-March and June 15, 2020. To address COVID-coagulopathy we developed a d-dimer-based anticoagulation protocol for patients with COVID-19 (Figure 1). We recorded anticoagulant use as either standard prophylactic, escalated prophylactic (low-dose intravenous unfractionated heparin titrated to achieve an anti-factor Xa level of 0.1-0.3 anti-Xa units or enoxaparin 0.5mg/kg subcutaneously every 12 hours) or standard therapeutic dose used during the hospitalization. The primary endpoints assessed were ISTH-defined major and clinically relevant non-major bleeding (CRNMB) events and survival. Secondary endpoints included incidence of breakthrough thrombosis and duration of hospitalization. Results: A total of 263 patients with COVID-19 were reviewed. Of these, 68.44% of patients received prophylactic, 12.55% escalated prophylactic and 19.01% therapeutic dosage. Of total, 129 (49%) were receiving ICU level of care. No major bleeding events were observed. The incidence of CRNMB was 4.56% in the whole cohort, which did not differ significantly between the escalated prophylactic and therapeutic groups (12% and 12.12%, respectively). Patients treated with standard prophylaxis had less CRNMB (1.11%), but this was not statistically significant in a multivariate analysis that included other confounding factors such as age, sex, ethnicity, BMI, comorbidity, HASBLED bleeding risk, and sepsis induced coagulopathy score (SICS). The mortality rate was 12.6% in the whole cohort (7.22%, 21.21% and 26% in prophylactic, escalated prophylactic, and therapeutic dosage, respectively). Factors significantly associated with increased mortality included age and ICU level of care (HR 1.10, 95%CI [1.05, 1.15] and HR 20.42, 95%CI [2.84, 146.72], respectively). The use of therapeutic dose heparin and high-flow nasal cannula demonstrate a survival benefit in multivariate analysis (HR 0.13, 95%CI [0.04,0.44] and HR 0.23, 95%CI [0.07, 0.72], respectively; Figure 2). Breakthrough thrombosis occurred in 7 (2.66%) patients; 1 (0.56%), 1 (3.03%) and 5 (10%)) in prophylactic, escalated prophylactic and therapeutic dosage, respectively but very few diagnostic tests were performed during this time period. Duration of hospitalization was significantly longer in the therapeutic dose group when compared to escalated prophylaxis and standard prophylactic groups. Conclusion: In this cohort of inpatients with COVID-19, there were no major bleeding events related to any dose of heparin or LMWH prophylaxis. By multivariate analysis, implementation of a d-dimer-titrated anticoagulation strategy was not associated with increased CRNMB. Therapeutic dose heparin based on a d-dimer-driven anticoagulation protocol was associated with a survival benefit in COVID19-infected patients. Limitations of this study include the retrospective observational nature and a lack of a uniform diagnostic protocol for patients with suspected VTE. Although no significant difference in bleeding events were observed in our study subgroups, randomized clinical trials are necessary to determine optimal thromboprophylaxis strategy in the COVID-19 population. Disclosures No relevant conflicts of interest to declare.

We propose mobile service consumption values based on a multi-dimensional value perspective by conducting an exploratory mixed-method design, including focus group interviews and face-to-face intercept surveys. We explored six dimensions of mobile service consumption values: convenience, effectiveness, enjoyment, reassurance, information, and epistemic values. The proposed value dimensions expand the scope of existing value studies by proposing additional or modified value dimensions. These dimensions reflect unique characteristics of mobile service values. In addition, the effects of mobile service consumption values on mobile service uses were examined. The results show that users’ value perceptions significantly influence their intention to use mobile services and that relative importance of value dimensions is different depending on types of mobile services. The exploration and verification of mobile service consumption values contributes theoretically to developing an expanded framework of consumption values in the mobile service field and to further understanding needs and motivations of mobile service users.

The cancer stem cell (CSC) paradigm posits that specific cells within a tumor, so-called CSC-like cells, have differing levels of tumorigenicity and chemoresistance. Original studies of CSCs identified them in human cancers and utilized mouse xenograft models to define the cancer initiating properties of these cells, thereby hampering the understanding of how immunity could affect CSCs. Indeed, few studies have characterized CSCs in the context of cancer immunoediting, and it is currently not clear how immunity could impact on the levels or stem-like behavior of CSCs. Using the well-studied 3′methylcholanthrene (MCA) model of primary sarcoma formation, we have defined a CSC-like population within MCA-induced sarcomas as expressing high levels of stem cell antigen-1 (Sca-1) and low levels of CD90. These Sca-1(+)CD90(−) CSC-like cells had higher tumor initiating ability, could spontaneously give rise to Sca-1-negative cells, and formed more sarcospheres than corresponding non-CSC-like cells. Moreover, when examining MCA-induced sarcomas that were in the equilibrium phase of cancer growth, higher levels of CSC-like cells were found compared to MCA-induced sarcomas in the escape phase of cancer progression. Notably, CSC-like cells also emerged during escape from anti-PD-1 or anti-CTLA4 therapy, thus suggesting that CSC-like cells could evade immune therapy. Finally, we demonstrate that paradoxically, interferon (IFN)-γ produced in vivo by immune cells could promote the emergence of CSC-like cells. Our findings define the existence of a Sca1(+)CD90(−) CSC-like population in the MCA-sarcoma model capable of differentiation, tumorsphere formation, and increased tumor initiation in vivo. These cells may also act as mediators of immune resistance during cancer immunoediting and immune therapy.

Evidence of cancer immunosurveillance and immunoediting processes has been primarily demonstrated in mouse models of chemically induced oncogenesis. Although these models are very tractable, they are characterized by high mutational loads that represent a minority of human cancers. In this study, we sought to determine whether cancer immunosurveillance and immunoediting could be demonstrated in a more clinically relevant oncogene-induced model of carcinogenesis, the MMTV-PyMT (PyMT) mammary carcinoma model. This model system in the FVB/NJ strain background was previously used to demonstrate that adaptive immunity had no role in limiting primary cancer formation and in fact promoted metastasis, thus calling into question whether cancer immunosurveillance operated in preventing the development of breast cancer. Our current study in the C57BL/6 strain backgrounds provides a different conclusion, as we report here the existence of an adaptive immunosurveillance of PyMT mammary carcinomas using two independent models of immune deficiency. PyMT mice bred onto a Rag1−/− background or immune suppressed by chronic tacrolimus therapy both demonstrated accelerated development of mammary carcinomas. By generating a bank of cell lines from these animals, we further show that a subset of PyMT cell lines had delayed growth after transplantation into wild-type (WT) syngeneic, but not immune-deficient hosts. This reduced growth rate in immunocompetent animals was characterized by an increase in immune cell infiltration and tissue differentiation. Furthermore, loss of the immune cell infiltration that characterized immunoediting of slow growing cell lines, changed them into fast growing variants capable of progressing in the immunocompetent model. In conclusion, our study provides evidence that immunosurveillance and immunoediting of PyMT-derived cell lines modulate tumor progression in this oncogene-induced model of cancer.

Regulatory T (Treg) cells play a central role in immune tolerance and prevention of aberrant immune responses. Several studies have suggested that the risk of graft-versus-host disease (GVHD) after allogeneic hematopoietic cell transplantation (HCT) can be ameliorated by increasing Tregs. We have developed an approach of in vivo expansion of Tregs with RGI-2001, a novel liposomal formulation of a synthetic derivative of alpha-galactosylceramide, a naturally occurring ligand that binds to CD1 and activates and expands invariant natural killer cells. In preclinical studies, a single intravenous infusion of RGI-2001 expanded Treg and could ameliorate GVHD in a mouse model of allogeneic HCT. To explore the role of RGI-2001 in clinical HCT, we initiated a phase 2A clinical trial (n = 29), testing 2 different doses of RGI-2001 administered as a single infusion on day 0 of allogeneic HCT. RGI-2001 was well tolerated and without infusion reactions or cytokine release syndrome. A subset of patients (8 of 29, 28%) responded to RGI-2001 by inducing a markedly increased number of cells with a Treg phenotype. The Treg had a high Ki-67 index and were almost exclusively Helios+ and Foxp3+, indicating that their accumulation was due to expansion of natural Treg. Notably, the incidence of grade 2 to 4 GVHD in the 8 patients who responded to RGI-2001 was 12.5%, compared with 52.4% in the 21 patients who did not respond. No grade 3 or 4 GVHD was observed in the responder group, compared with a 9.5% incidence among nonresponders. Immunosuppression with sirolimus was also associated with a low incidence of GVHD, suggesting that RGI-2001 may have synergized with sirolimus to promote Treg expansion.

Although many studies have been conducted to determine factors that influence Internet adoption and use by older adults, the focus has tended to be on investigating the consumers' intention to adopt the Internet. Although the factors that influence intention to adopt lead to nonusers' initial Internet adoption, they do not guarantee continued and frequent Internet use thereafter. Therefore, our aims in this study were to identify the factors that facilitate and impede the process of Internet adoption by people aged 40 years and over. We conducted surveys with 410 consumers aged between 40 and 70 years and found that there are influential factors that are different and some that are identical at different stages of the Internet adoption process. Based on these findings, we discuss implications and suggest effective strategies to encourage consumers aged between 40 and 70 years to adopt and continue to use the Internet.

This paper is an empirical study identifying the role of a relationship-specific capability of building capabilities through relationships (CBC) when suppliers put efforts into increasing their perceived market effectiveness by managing the effects of relationship quality. The relationship between relationship quality and effectiveness is mediated by CBC. Suppliers in a supply chain form different levels of relationship quality with partners in response to market conditions and industry characteristics. Relationship marketing by suppliers requires a deep understanding of the role of CBC that is developed by a supplier and an effective utilization of CBC to lead an effective relationship to better outcomes. This leads to maximizing of the competitive advantages for suppliers and will help maintain effective relationships.

The main goal of this study is to examine the effects of the extrinsic and intrinsic motivation, and the psychological burden on mature consumers regarding their Internet usage. “Psychological burden” refers to the emotional constraints such as anxiety and fears that make using technology uncomfortable. Here, we developed a research model and formulated hypotheses based on the Technology Acceptance Model (TAM). A survey of mature Internet users was conducted and the proposed model was tested using a Structural Equation Modeling (SEM) technique. To cite this document: Haeyoung Jeong, Semi Han, and Euehun Lee, " The role of psychological burden in mature consumers to adopt the internet", International Journal of Electronic Commerce Studies, Vol.4, No.1, pp.135-138, 2013. Permanent link to this document: http://dx.doi.org/10.7903/ijecs.1139

Reaction of [AuCl(SMe2)] with NaL·H2O (L = ethyl(pyridine-4-yl methyl)dithiocarbamate (epdtc) or methyl(2-(pyridin-2-yl)ethyl)dithiocarbamate (mpdtc)) affords a series of neutral dinuclear gold(I) complexes bridged by each dithiocarbamate ligand, [Au(L)]2. The successive reaction of [Au(L)]2 with organic acids such as isophthalic acid (m-pa) and maleic acid (ma) produces 1:1 adducts, [Au(L)]2·(organic acid). The crystal structure of [Au(L)]2·(m-pa) is a 1D polymer formed via hydrogen bonds between the free pyridyl and the carboxylic acid moiety. For the dinuclear moiety, strong intradinuclear aurophilic interactions (Au(I)–Au(I) = 2.7783(8) A and 2.7525(7) A) exist, but interdinuclear interactions are weak (3.2551(8)–3.2733(8) A). The dinuclear gold(I) complexes, [Au(epdtc)]2 and [Au(mpdtc)]2, show a bright luminescence at 562.5 and 552.0 nm in solid state, respectively, but their organic acid adducts, [Au(L)]2·(organic acid), have no luminescent properties. This dramatic difference in properties between the gold(I) complexes and their adducts may be ascribed to the weakness of the internuclear Au(I)–Au(I) interaction including crystal packing.

Reversible interconversion between inter- and intramolecular Au⋯Au interactions induces luminescence on/off switching in solid state. For the gold(I) photoluminescence system, intermolecular aurophilic interaction is a more significant factor than intramolecular aurophilic interaction.

Kaposi Sarcoma, an angioproliferative vascular tumor, is the most common malignancy in patients with HIV and presents a treatment conundrum because of its variable natural history. Lenalidomide is a drug that has immune-modulatory, anti-neoplastic, and anti-angiogenic properties. It is used in the treatment of myelodysplastic disease and multiple myeloma, but its in vivo effects on peripheral blood immune activity is not fully explored. In this preliminary report from a phase I/II trial of lenalidomide in the treatment of HIV associated Kaposi Sarcoma, we found that lenalidomide increased the number and percentage of T regulatory phenotype cells in the peripheral blood. In patients with measurable regression of Kaposi Sarcoma lesion size as well as number of lesions, there was also an observable accumulation in FOXP3 expressing cells in the Kaposi Sarcoma lesion. These findings enable us to speculate on three novel concepts: 1) lenalidomide increases the frequency of circulating T regulatory phenotype cells, 2) lenalidomide’s anti-angiogenic mechanism may be due to T regulatory cell induction, and 3) in contrast to their role in promoting tumor growth by inhibiting tumor immunosurveillance, T regulatory cells may inhibit angioproliferative tumors therefore act as an effective therapeutic agent for tumors such as Kaposi Sarcoma.

The cancer stem cell (CSC) hypothesis stipulates that tumors follow a hierarchical organization where a subpopulation of cells endowed with stem cell characteristics initiates and maintains the malignant progression. Using the murine MCA sarcoma model system, a widely recognized model for studying cancer immunosurveillance and rejection mechanisms, we sought to explore how hierarchical tumor progression occurs during cancer immunosurveillance. The first step was to define CSC in the MCA sarcoma model. We identified an interesting heterogeneity of the tumor population based on Sca1 and CD90 expression. Purification of the Sca1+ and Sca1+/CD90+ in various cell lines and subsequent in vitro culture demonstrated that the Sca1+/CD90-population is able to regenerate the initial tumor heterogeneity. Transplantation of those two populations in RAGxγc-/- hosts demonstrated either a more rapid onset of sarcoma in mice injected with Sca1+ cells. Interestingly, phenotypic analysis of escaping tumors revealed an increase in Sca1+ cells. Finally, in vitro treatment with IFNg led to a substantial increase in Sca1 expression that correlated with an increase in cells' stemness properties as suggested by the elevated sphere forming capacity of IFNg treated cells. This data suggest that cancer stemness may be modulated by anti-cancer immune responses and may represent an additional mechanism of tumor immune escape.