Heart Transplant - A Medical Dictionary, Bibliography, and Annotated Research Guide to Internet References

HEART

TRANSPLANT A M EDICAL D ICTIONARY , B IBLIOGRAPHY , AND A NNOTATED R ESEARCH G UIDE TO I NTERNET R EFERENCES

J AMES N. P ARKER , M.D. AND P HILIP M. P ARKER , P H .D., E DITORS

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ICON Health Publications ICON Group International, Inc. 4370 La Jolla Village Drive, 4th Floor San Diego, CA 92122 USA Copyright ©2004 by ICON Group International, Inc. Copyright ©2004 by ICON Group International, Inc. All rights reserved. This book is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher. Printed in the United States of America. Last digit indicates print number: 10 9 8 7 6 4 5 3 2 1

Publisher, Health Care: Philip Parker, Ph.D. Editor(s): James Parker, M.D., Philip Parker, Ph.D. Publisher's note: The ideas, procedures, and suggestions contained in this book are not intended for the diagnosis or treatment of a health problem. As new medical or scientific information becomes available from academic and clinical research, recommended treatments and drug therapies may undergo changes. The authors, editors, and publisher have attempted to make the information in this book up to date and accurate in accord with accepted standards at the time of publication. The authors, editors, and publisher are not responsible for errors or omissions or for consequences from application of the book, and make no warranty, expressed or implied, in regard to the contents of this book. Any practice described in this book should be applied by the reader in accordance with professional standards of care used in regard to the unique circumstances that may apply in each situation. The reader is advised to always check product information (package inserts) for changes and new information regarding dosage and contraindications before prescribing any drug or pharmacological product. Caution is especially urged when using new or infrequently ordered drugs, herbal remedies, vitamins and supplements, alternative therapies, complementary therapies and medicines, and integrative medical treatments. Cataloging-in-Publication Data Parker, James N., 1961Parker, Philip M., 1960Heart Transplant: A Medical Dictionary, Bibliography, and Annotated Research Guide to Internet References / James N. Parker and Philip M. Parker, editors p. cm. Includes bibliographical references, glossary, and index. ISBN: 0-597-84446-1 1. Heart Transplant-Popular works. I. Title.

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Disclaimer This publication is not intended to be used for the diagnosis or treatment of a health problem. It is sold with the understanding that the publisher, editors, and authors are not engaging in the rendering of medical, psychological, financial, legal, or other professional services. References to any entity, product, service, or source of information that may be contained in this publication should not be considered an endorsement, either direct or implied, by the publisher, editors, or authors. ICON Group International, Inc., the editors, and the authors are not responsible for the content of any Web pages or publications referenced in this publication.

Copyright Notice If a physician wishes to copy limited passages from this book for patient use, this right is automatically granted without written permission from ICON Group International, Inc. (ICON Group). However, all of ICON Group publications have copyrights. With exception to the above, copying our publications in whole or in part, for whatever reason, is a violation of copyright laws and can lead to penalties and fines. Should you want to copy tables, graphs, or other materials, please contact us to request permission (E-mail: [email protected]). ICON Group often grants permission for very limited reproduction of our publications for internal use, press releases, and academic research. Such reproduction requires confirmed permission from ICON Group International, Inc. The disclaimer above must accompany all reproductions, in whole or in part, of this book.

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Acknowledgements The collective knowledge generated from academic and applied research summarized in various references has been critical in the creation of this book which is best viewed as a comprehensive compilation and collection of information prepared by various official agencies which produce publications on heart transplant. Books in this series draw from various agencies and institutions associated with the United States Department of Health and Human Services, and in particular, the Office of the Secretary of Health and Human Services (OS), the Administration for Children and Families (ACF), the Administration on Aging (AOA), the Agency for Healthcare Research and Quality (AHRQ), the Agency for Toxic Substances and Disease Registry (ATSDR), the Centers for Disease Control and Prevention (CDC), the Food and Drug Administration (FDA), the Healthcare Financing Administration (HCFA), the Health Resources and Services Administration (HRSA), the Indian Health Service (IHS), the institutions of the National Institutes of Health (NIH), the Program Support Center (PSC), and the Substance Abuse and Mental Health Services Administration (SAMHSA). In addition to these sources, information gathered from the National Library of Medicine, the United States Patent Office, the European Union, and their related organizations has been invaluable in the creation of this book. Some of the work represented was financially supported by the Research and Development Committee at INSEAD. This support is gratefully acknowledged. Finally, special thanks are owed to Tiffany Freeman for her excellent editorial support.

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About the Editors James N. Parker, M.D. Dr. James N. Parker received his Bachelor of Science degree in Psychobiology from the University of California, Riverside and his M.D. from the University of California, San Diego. In addition to authoring numerous research publications, he has lectured at various academic institutions. Dr. Parker is the medical editor for health books by ICON Health Publications. Philip M. Parker, Ph.D. Philip M. Parker is the Eli Lilly Chair Professor of Innovation, Business and Society at INSEAD (Fontainebleau, France and Singapore). Dr. Parker has also been Professor at the University of California, San Diego and has taught courses at Harvard University, the Hong Kong University of Science and Technology, the Massachusetts Institute of Technology, Stanford University, and UCLA. Dr. Parker is the associate editor for ICON Health Publications.

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About ICON Health Publications To discover more about ICON Health Publications, simply check with your preferred online booksellers, including Barnes&Noble.com and Amazon.com which currently carry all of our titles. Or, feel free to contact us directly for bulk purchases or institutional discounts: ICON Group International, Inc. 4370 La Jolla Village Drive, Fourth Floor San Diego, CA 92122 USA Fax: 858-546-4341 Web site: www.icongrouponline.com/health

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Table of Contents FORWARD .......................................................................................................................................... 1 CHAPTER 1. STUDIES ON HEART TRANSPLANT ................................................................................ 3 Overview........................................................................................................................................ 3 The Combined Health Information Database................................................................................. 3 Federally Funded Research on Heart Transplant .......................................................................... 4 E-Journals: PubMed Central ....................................................................................................... 60 The National Library of Medicine: PubMed ................................................................................ 64 CHAPTER 2. NUTRITION AND HEART TRANSPLANT .................................................................... 113 Overview.................................................................................................................................... 113 Finding Nutrition Studies on Heart Transplant ....................................................................... 113 Federal Resources on Nutrition ................................................................................................. 119 Additional Web Resources ......................................................................................................... 119 CHAPTER 3. DISSERTATIONS ON HEART TRANSPLANT................................................................ 121 Overview.................................................................................................................................... 121 Dissertations on Heart Transplant ............................................................................................ 121 Keeping Current ........................................................................................................................ 121 CHAPTER 4. CLINICAL TRIALS AND HEART TRANSPLANT .......................................................... 123 Overview.................................................................................................................................... 123 Recent Trials on Heart Transplant ............................................................................................ 123 Keeping Current on Clinical Trials ........................................................................................... 125 CHAPTER 5. PATENTS ON HEART TRANSPLANT .......................................................................... 127 Overview.................................................................................................................................... 127 Patents on Heart Transplant ..................................................................................................... 127 Patent Applications on Heart Transplant.................................................................................. 134 Keeping Current ........................................................................................................................ 138 CHAPTER 6. BOOKS ON HEART TRANSPLANT .............................................................................. 139 Overview.................................................................................................................................... 139 Book Summaries: Online Booksellers......................................................................................... 139 Chapters on Heart Transplant ................................................................................................... 141 CHAPTER 7. MULTIMEDIA ON HEART TRANSPLANT ................................................................... 143 Overview.................................................................................................................................... 143 Video Recordings ....................................................................................................................... 143 CHAPTER 8. PERIODICALS AND NEWS ON HEART TRANSPLANT ................................................ 145 Overview.................................................................................................................................... 145 News Services and Press Releases.............................................................................................. 145 Academic Periodicals covering Heart Transplant...................................................................... 148 CHAPTER 9. RESEARCHING MEDICATIONS .................................................................................. 151 Overview.................................................................................................................................... 151 U.S. Pharmacopeia..................................................................................................................... 151 Commercial Databases ............................................................................................................... 152 Researching Orphan Drugs ....................................................................................................... 152 APPENDIX A. PHYSICIAN RESOURCES .......................................................................................... 157 Overview.................................................................................................................................... 157 NIH Guidelines.......................................................................................................................... 157 NIH Databases........................................................................................................................... 159 Other Commercial Databases..................................................................................................... 161 APPENDIX B. PATIENT RESOURCES ............................................................................................... 163 Overview.................................................................................................................................... 163 Patient Guideline Sources.......................................................................................................... 163 Finding Associations.................................................................................................................. 171 APPENDIX C. FINDING MEDICAL LIBRARIES ................................................................................ 175

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Overview.................................................................................................................................... 175 Preparation................................................................................................................................. 175 Finding a Local Medical Library................................................................................................ 175 Medical Libraries in the U.S. and Canada ................................................................................. 175 ONLINE GLOSSARIES................................................................................................................ 181 Online Dictionary Directories ................................................................................................... 182 HEART TRANSPLANT DICTIONARY.................................................................................... 183 INDEX .............................................................................................................................................. 249

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FORWARD In March 2001, the National Institutes of Health issued the following warning: "The number of Web sites offering health-related resources grows every day. Many sites provide valuable information, while others may have information that is unreliable or misleading."1 Furthermore, because of the rapid increase in Internet-based information, many hours can be wasted searching, selecting, and printing. Since only the smallest fraction of information dealing with heart transplant is indexed in search engines, such as www.google.com or others, a non-systematic approach to Internet research can be not only time consuming, but also incomplete. This book was created for medical professionals, students, and members of the general public who want to know as much as possible about heart transplant, using the most advanced research tools available and spending the least amount of time doing so. In addition to offering a structured and comprehensive bibliography, the pages that follow will tell you where and how to find reliable information covering virtually all topics related to heart transplant, from the essentials to the most advanced areas of research. Public, academic, government, and peer-reviewed research studies are emphasized. Various abstracts are reproduced to give you some of the latest official information available to date on heart transplant. Abundant guidance is given on how to obtain free-of-charge primary research results via the Internet. While this book focuses on the field of medicine, when some sources provide access to non-medical information relating to heart transplant, these are noted in the text. E-book and electronic versions of this book are fully interactive with each of the Internet sites mentioned (clicking on a hyperlink automatically opens your browser to the site indicated). If you are using the hard copy version of this book, you can access a cited Web site by typing the provided Web address directly into your Internet browser. You may find it useful to refer to synonyms or related terms when accessing these Internet databases. NOTE: At the time of publication, the Web addresses were functional. However, some links may fail due to URL address changes, which is a common occurrence on the Internet. For readers unfamiliar with the Internet, detailed instructions are offered on how to access electronic resources. For readers unfamiliar with medical terminology, a comprehensive glossary is provided. For readers without access to Internet resources, a directory of medical libraries, that have or can locate references cited here, is given. We hope these resources will prove useful to the widest possible audience seeking information on heart transplant. The Editors

1

From the NIH, National Cancer Institute (NCI): http://www.cancer.gov/cancerinfo/ten-things-to-know.

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CHAPTER 1. STUDIES ON HEART TRANSPLANT Overview In this chapter, we will show you how to locate peer-reviewed references and studies on heart transplant.

The Combined Health Information Database The Combined Health Information Database summarizes studies across numerous federal agencies. To limit your investigation to research studies and heart transplant, you will need to use the advanced search options. First, go to http://chid.nih.gov/index.html. From there, select the “Detailed Search” option (or go directly to that page with the following hyperlink: http://chid.nih.gov/detail/detail.html). The trick in extracting studies is found in the drop boxes at the bottom of the search page where “You may refine your search by.” Select the dates and language you prefer, and the format option “Journal Article.” At the top of the search form, select the number of records you would like to see (we recommend 100) and check the box to display “whole records.” We recommend that you type “heart transplant” (or synonyms) into the “For these words:” box. Consider using the option “anywhere in record” to make your search as broad as possible. If you want to limit the search to only a particular field, such as the title of the journal, then select this option in the “Search in these fields” drop box. The following is what you can expect from this type of search: •

Dental Management of the Heart Transplant Patient Source: General Dentistry. 40(2): 126-131. March-April 1992. Summary: This article brings readers up to date on the dental management of heart transplant patients. Topics include the historical development of heart transplantation, including survival rates, postoperative care, and patient selection; complications following heart transplantation, including graft rejection, immunosuppression, accelerated atherosclerosis of the graft coronary arteries, side effects of agents used for immunosuppression, and excess bleeding as a result of anticoagulation medicine; dental management of these patients, including the pretreatment dental evaluation, retention of teeth, treatment of patients with valvular disease, and preventive techniques; and managing invasive dental treatment for posttransplant patients, including the need for antibiotic prophylaxis, handling excessive bleeding and reactions to stress, the use of

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Heart Transplant

steroids, and myocardial infarction. The authors conclude that the two most important roles for dentistry in managing heart transplant patients are to be involved before the transplant, so areas of active infection can be identified and treated before the start of immunosuppressive therapy, and to initiate an aggressive preventive dentistry program for the patient. 7 tables. 22 references. •

Reversion of Gingival Hyperplasia in a Heart Transplant Patient Upon Interruption of Cyclosporine Therapy Source: SCD. Special Care in Dentistry. 16(1): 18-21. January-February 1996. Summary: This article presents a case of reversion of gingival hyperplasia in a heart transplant patient upon interruption of cyclosporine therapy. A heart transplant patient undergoing a combined cyclosporine and prednisone treatment was monitored during the 18 months following transplantation. Complete oral and dental examinations were performed on a set schedule; data collected included gingival hyperplasia secondary to cyclosporine use, and clinical and periodontal variables. Cyclosporine treatment was replaced by azathioprine treatment in month 10 because the patient was experiencing nephrotoxicity. Between months 9 and 18, gingival hyperplasia regressed by 26.5 percent due to reductions in the fibrous connective tissue mass, fibroblasts, and inflammatory infiltration. A control group included 13 heart transplant patients subject to equivalent conditions except for discontinuance of cyclosporine treatment. Seven of these patients had developed hyperplasia by month 9. Results provide further evidence for the causal relationship between cyclosporine therapy and gingival hyperplasia and suggest that this side-effect is reversible. 7 figures. 7 references. (AA-M).

Federally Funded Research on Heart Transplant The U.S. Government supports a variety of research studies relating to heart transplant. These studies are tracked by the Office of Extramural Research at the National Institutes of Health.2 CRISP (Computerized Retrieval of Information on Scientific Projects) is a searchable database of federally funded biomedical research projects conducted at universities, hospitals, and other institutions. Search the CRISP Web site at http://crisp.cit.nih.gov/crisp/crisp_query.generate_screen. You will have the option to perform targeted searches by various criteria, including geography, date, and topics related to heart transplant. For most of the studies, the agencies reporting into CRISP provide summaries or abstracts. As opposed to clinical trial research using patients, many federally funded studies use animals or simulated models to explore heart transplant. The following is typical of the type of information found when searching the CRISP database for heart transplant: •

Project Title: ADENOVIRAL/LENTIVIRAL MODIFICATION

VECTORS

FOR

GENETIC

Principal Investigator & Institution: Mc Gregor, Christopher G.; Mayo Clinic Rochester 200 1St St Sw Rochester, Mn 55905 2 Healthcare projects are funded by the National Institutes of Health (NIH), Substance Abuse and Mental Health Services (SAMHSA), Health Resources and Services Administration (HRSA), Food and Drug Administration (FDA), Centers for Disease Control and Prevention (CDCP), Agency for Healthcare Research and Quality (AHRQ), and Office of Assistant Secretary of Health (OASH).

Studies

5

Timing: Fiscal Year 2002; Project Start 01-SEP-2002; Project End 31-AUG-2003 Summary: The broad long-term objectives of this proposal are to achieve targeted, efficient and durable gene transfer to the transplanted heart and, using biologically relevant genes for isoforms of nitric oxide synthase (NOS), to normalize coronary arterial vasoreactivity and reduce cardiac allograft vasculopathy (CAV) after allotransplantation in both a small and large animal model. The central hypotheses of this proposal are that, using the unique transplant setting, targeted, efficient and durable gene transduction of blood vessels of the heart or the myocardium can be achieved and that abnormalities in coronary vascular relaxation and the development of CAV after heart transplantation can be reduced by efficient cardiac transduction with endothelial or inducible NOS (eNOS or iNOS). CAV is the greatest obstacle to long-term patient survival after cardiac transplantation. Gene therapy may be particularly applicable in the setting of transplantation as the donor organ is uniquely available for genetic modification ex vivo prior to implantation into a recipient. Major challenges to successful clinical gene genetic modification ex vivo prior to implantation into a recipient. Major challenges to successful clinical gene therapy include the need for optimal vectors and delivery systems to transfer genetic material to tissues in vivo. Recently, for the first time, physical and chemical conditions of gene delivery to the heart have been shown to allow selective targeting of the vector to the media of the coronary arteries of the myocardium. Using a normothermic perfusion system, the usual period of storage of the donor heart before transplantation can be transformed into a period for optimal gene delivery without affecting the viability of the graft. The first aim of transformed into a period for optimal gene delivery without affecting the viability of the graft. The first aim of the current proposal is to identify the most suitable vector (adenovirus or lentivirus) and delivery system using chemical modification of a normothermic perfusion system for efficient, targeted and durable gene delivery in the heterotopic rat heart transplant model. The second aim is to study, using the most suitable vector and same delivery system from Specific Aim 1, the effects of eNOS or iNOS gene transfer to either the coronary vasculature or myocardium of the donor heart on coronary arterial vascular reactivity and on CAV after heterotopic pig heart allotransplantation. NOS will be studied as the gene of choice as reduced nitric oxide bioavailability is characteristic of vessels undergoing CAV. Abnormal endothelium dependent relaxation precedes CAV, so that successful NOS gene transfer might be expected to impact on the early stages of the disease. Before gene transfer technology to the transplanted heart can progress to the clinic, satisfactory experience in a large animal model will be necessary. The porcine model is particular suitable from a physiological and pathological viewpoint and is also the animal of choice for future clinical xenotransplantation. Success in achieving the specific aims of this proposal opens up the potential for clinical gene therapy to avoid CAV after heart transplantation. Implications also exist for the application of these techniques for the modification of non-allograft arteriosclerosis. Website: http://crisp.cit.nih.gov/crisp/Crisp_Query.Generate_Screen •

Project Title: AIF-1 EXPRESSION IN VSMC GROWTH AND ARTERIOPATHY Principal Investigator & Institution: Autieri, Michael V.; Assistant Professor; Physiology; Temple University 406 Usb, 083-45 Philadelphia, Pa 19122 Timing: Fiscal Year 2002; Project Start 20-MAR-2001; Project End 28-FEB-2005 Summary: (Applicant's abstract): Vascular restenosis induced by arterial trauma is one of the most critical factors which limits the success o solid organ transplantation and coronary interventional procedures. A popular hypothesis is that the cytokine-induced

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Heart Transplant

activation and proliferation of VSMC in the media, culminating in intimal hyperplasia, is the most critical cellular event in formation of both cardiac allograft vasculopathy (CAV) and balloon angioplastyinduced restenosis. Identification and functional characterization gene products involved in VSMC activation is a promising approach for the identification of targets to combat proliferative arteriopathy observed in vascular proliferative disorders. Our hypothesis is that allograft inflammatory factor-I (AIF-1) promotes development of vascular proliferative disease based on its ability to respond to inflammatory cytokines and participate in the growth stimulatory pathways leading to proliferation of VSMC. We have recently shown that modulation of AIF- 1 levels in human VSMC impacts the growth of these cells. The first aim of this project will determine the mechanism of AIF-l growth promoting effects in human VSMC through a combination of flow cytometric analysis and investigation of expression and turnover of cell cycle-associated proteins. We will also identify regions that mediate these effects by site-specific modification of the AIF- 1 protein. We have determined that AIF- 1 partners with several cytoplasmic proteins, including a newly described growth factor-activated lipid kinase termed LCBK5. The second aim of this proposal will determine the functional significance of the AIF- 1-LCBK5 interaction and characterize the other AIF-1interacting peptides we have identified. Expression of AIF- 1 transcript is induced in mitogen-stimulated peripheral blood lymphocytes (PBL), and its expression in endomyocardial biopsies from transplanted hearts correlates with ISHLT rejection scores. A final aim of this proposal will correlate AIF-1 transcript levels in endomyocardial biopsies and PBL from heart transplant recipients with development of arteriopathy as determined by several clinical and imaging indices. It is anticipated that completion of these studies will implicate expression of this novel protein as a target of anti-restenotic therapy and a surrogate marker of transplant restenosis. Website: http://crisp.cit.nih.gov/crisp/Crisp_Query.Generate_Screen •

Project Title: APOPTOSIS

ALLOGRAFT

TOLERANCE

WITH

FAS/FASL-MEDIATED

Principal Investigator & Institution: Shirwan, Haval; Associate Professor; Microbiology and Immunology; University of Louisville University of Louisville Louisville, Ky 40292 Timing: Fiscal Year 2002; Project Start 15-DEC-2001; Project End 30-NOV-2005 Summary: Transplantation of vascularized allografts is an effective therapeutic alternative for patients with end-stage organ failure. Transplantation of organs between genetically different individuals, however, is limited by our ability to control the immunological rejection of the graft by the recipient. Immunosuppressive drugs may reduce the severity of rejection, but fail to create a state of permanent specific tolerance to the graft. We herein propose an immunomodulatory approach using a modified form of FasL with potent apoptotic activity to eliminate alloreactive T cells for the prevention of cardiac allograft rejection and induction of tolerance. FasL-induced apoptosis is the main mechanism of activation-induced cell death that is responsible for immune homeostasis and self-tolerance. The use of wild type (wt)FasL to prevent allograft rejection has been controversial. FasL is initially synthesized as a membranous molecule that induces apoptosis when prevention the cell surface. wtFasL is also shed from the cell surface by metalloproteinases within minutes of expression and the soluble form is antiapoptotic and chemotactic for neutrophils. We hypothesize that FasL can be used as an immunomodulatory molecule if its apoptotic activity is separated from anti-apoptotic and chemotactic functions. We generated modified forms of FasL with potent apoptotic activity and developed a novel approach to express FasL at the protein level on the surface of antigen- presenting cells (APCs) and vascular endothelium within 1 hour. In

Studies

7

preliminary experiments, we demonstrated that delivery of FasL on donor APCs blocked alloreactive responses in naive and presensitized animals and prevented islet allograft rejection. Expression of FasL protein on vascular endothelium under conditions adapted from clinical settings prolonged survival of cardiac allografts. In this proposal, rats and mice will be immunized with allogeneic APCs expressing FasL at various times pre-and post- transplantation. FasL will also be expressed on the surface of heart endothelium for immune evasion and prevention of rejection. Several mutant and transgenic animals will be used to test whether apoptosis induced by FasL is the main mechanism of the observed immune nonresponsiveness. This protein-based approach may be readily applied to the clinic and may provide a significant advantage because of its safety and simplicity as compared with immunomodulatory approaches using DNAbased expression. Website: http://crisp.cit.nih.gov/crisp/Crisp_Query.Generate_Screen •

Project Title: AN ETHICAL ANALYSIS OF ORGAN ALLOCATION POLICIES Principal Investigator & Institution: Fox, Mark D.; Pediatrics; University of Oklahoma Hlth Sciences Ctr Health Sciences Center Oklahoma City, Ok 73126 Timing: Fiscal Year 2003; Project Start 01-JUL-2003; Project End 30-JUN-2008 Summary: (provided by applicant): The purpose of this career development award is to enable Dr. Fox to develop the requisite skills to become an independent investigator, scholar, and resource in transplant ethics and policy. Through a structured program of didactic training and mentored research, the applicant proposes to develop an "evidence-based" ethical analysis of organ allocation policy, with specific reference to heart transplantation. This ethical analysis will be predicated on the development of skills in health services/outcomes research relevant to transplantation. The overall goal of this project is to provide an evidence-based ethical analysis of allocation policy informed by data regarding cardiac transplantation outcomes, and to determine if the impact of the policy changes enacted matches the stated goals of allocation policy. The fundamental hypothesis to be tested is that the changes in the allocation policy for heart transplantation have not produced outcomes consistent with the stated goals for transplantation. This hypothesis will be systematically pursued through the following five specific aims: 1) to develop methods for analyzing clinical outcomes for patients listed for cardiac transplantation in the United States, using the Scientific Registry of Transplant Recipients database; 2) to examine changes over time in the allocation policy regarding heart transplantation, with particular attention to how criteria defining medical urgency impact allocation decisions; 3) to evaluate the impact of changes in heart allocation policies with respect to various outcomes (pretransplant mortality, posttransplant survival, and the need for re-transplantation); 4) to examine differences in value assigned to possible outcomes, as reflected in preferences for allocation strategies, among patients and non patients, transplant professionals and other health care providers; and 5) to develop a policy analysis of other potential models for heart allocation to determine their clinical, political, and moral viability. Upon completion of the career development award, Dr. Fox will be able to function as an independent investigator in the interface between ethics and health services research. Website: http://crisp.cit.nih.gov/crisp/Crisp_Query.Generate_Screen

•

Project Title: ANGIOGENESIS AND CHRONIC REJECTION Principal Investigator & Institution: Briscoe, David M.; Children's Hospital (Boston) Boston, Ma 021155737

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Heart Transplant

Timing: Fiscal Year 2002; Project Start 01-APR-2000; Project End 31-MAR-2005 Summary: This abstract is not available. Website: http://crisp.cit.nih.gov/crisp/Crisp_Query.Generate_Screen •

Project Title: ANTIMHC ANTIBODY EFFECTS ON ENDOTHELIUM AND MUSCLE Principal Investigator & Institution: Reed, Elaine F.; Professor; Pathology and Laboratory Medicine; University of California Los Angeles 10920 Wilshire Blvd., Suite 1200 Los Angeles, Ca 90024 Timing: Fiscal Year 2003; Project Start 01-JAN-1999; Project End 31-DEC-2007 Summary: (provided by applicant): Accelerated transplant arteriosclerosis (TA), a manifestation of chronic rejection, is the leading cause of graft failure. The development of anti-HLA antibodies to donor HLA antigens is a major risk factor associated with TA. The overall goal of this proposal is to elucidate the signal transduction pathways that mediate HLA class I induced cell proliferation and the development of TA. Under specific aim #1, we will establish whether anti-HLA antibodies induce tyrosine phoshphorylation of focal adhesion proteins and assembly of signaling complexes via an actin cytoskeleton dependent pathway in endothelium and smooth muscle. For this, we will establish whether exposure of cultured endothelial cells (EC) and smooth muscle cells (SMC) to monoclonal anti-HLA antibodies and anti-HLA antibodies from transplant patients with chronic rejection is accompanied by FAK phosphorylation and the generation of FAK/Src/Paxillin signaling complexes. We will determine if the phosphorylation of focal adhesion proteins is accompanied by alterations in the organization of the actin cytoskeleton and in the assembly of focal adhesions. We will explore the role of ROK, MLC phosphatase and ERK as upstream components of the class I signaling pathway. We will also determine if class I signaling stimulates antiapoptotic signals by inducing tyrosine phosphorylation of PI3-kinase, Akt and Bad. Under specific aim #2, we will identify the signaling pathways leading to MHC class I induced FGF receptor translocation in EC and SMC. For this, we will determine the role of the actin cytoskeleton, phosphorylation of FAK, Src, paxillin and assembly of focal adhesions in class I mediated FGFR translocation to distinct subcellular locations using flow cytometry and confocal microscopy. We will also assess the importance of ROK, ERK, MLC phosphatase in class I mediated FGF receptor translocation. The contribution of the FGF receptor tyrosine kinase activity and ERK phosphorylation to class I induced cell proliferation will be established. Under aim #3, we will assess the expression of class I induced tyrosine phosphorylation, FGF receptors and anti-apoptotic proteins in clinical biopsy specimens from cardiac allografts with and without evidence of transplant arteriosclerosis. We will determine the correlation between protein phosphorylation events and protein expression with the incidence and time of onset of transplant arteriosclerosis and development of anti-HLA antibodies. Website: http://crisp.cit.nih.gov/crisp/Crisp_Query.Generate_Screen

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Project Title: APCS IN CHRONIC HEART REJECTION Principal Investigator & Institution: Rosengard, Bruce R.; Assistant Professor; Surgery; University of Pennsylvania 3451 Walnut Street Philadelphia, Pa 19104 Timing: Fiscal Year 2002; Project Start 01-MAY-2001; Project End 30-APR-2004 Summary: (Verbatim from the Applicant's Abstract): Cardiac transplantation is established therapy for the treatment of end-stage heart failure. However, chronic rejection in the form of accelerated arteriosclerosis remains the primary cause of late

Studies

9

death after heart transplantation. Despite the development of several new drugs to combat rejection, the incidence of this form of chronic rejection has not changed. We have hypothesized that endothelial cells, which line coronary arteries, are capable of directly activating CD8+ T cells, which may play an important role in the development of graft vascular disease. We have established both in vitro and in vivo mouse models to study this process. The broad objective of this grant proposal is to define the differences in the ability of murine endothelium to activate CD4+ and CD8+ T cells in vitro and then to use analogous in vivo models to define the allorecognition pathways and effector mechanisms responsible for graft vascular disease. To achieve this goal, we will: 1. Test the hypothesis that endothelium activates both unprimed and primed CD8t T cells preferentially due to a less stringent requirement for costimulation. 2. Test the hypothesis that endothelium is a suitable target for CD8+ T cell cytotoxicity predominantly via the Fas/FasL pathway. 3. Test the hypothesis that graft vascular disease is a CDK about-dependent process. In summary, this proposal will determine whether endothelium has the capacity to stimulate CD8F T cells and the ability to act as targets for CD8+ cytotoxic T cells, which is sufficient to induce graft vasculopathy in a mouse model. Insights from this study will undoubtedly provide information that will lead to rational strategies to help prevent this lethal complication of human heart transplantation. Website: http://crisp.cit.nih.gov/crisp/Crisp_Query.Generate_Screen •

Project Title: APPLIED GENOMICS IN CARDIOPULMONARY DISEASE Principal Investigator & Institution: Haponik, Edward F.; Professor of Internal Medicine; Medicine; Johns Hopkins University 3400 N Charles St Baltimore, Md 21218 Timing: Fiscal Year 2002; Project Start 30-SEP-2000; Project End 31-JUL-2004 Summary: The Clinical Core will serve as the coordinating center for patient recruitment, specimen procurement and data base management. It is the mission of this Core to identify and provide disease-specific candidate genes from patients with such clinical disorders as acute lung injury, COPD, cystic fibrosis, asthma, pulmonary hypertension, pulmonary fibrosis, ischemic heart failure and both lung and cardiac transplant rejection. This core will also be responsible for the establishment of a Cardiopulmonary Tissue Repository that will maintain an archive of cryopreserved tissues and maintain an accurate data base of patient demographic and clinical data for correlation with biological end points produced by cDNA microarray. Following patient consent and registration, tissue samples and peripheral blood are delivered to the Core laboratory. The freezing facility will also serve as a repository for cyropreserved human lung and cardiac specimens. The Core Investigators will meet regularly to review all diagnostic materials on each specimen procured including histochemical stains and biopsies in order to determine a precise diagnosis and relevant demographic and clinical data for entry into the Project's data base which will include critical variables for the analysis of the biological data obtained. Website: http://crisp.cit.nih.gov/crisp/Crisp_Query.Generate_Screen

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Project Title: BIORAD ASPERGILLOSIS

GALACTOMANNAN

EIA

FOR

DIAGNOSIS

OF

Principal Investigator & Institution: Marr, Kieren A.; Fred Hutchinson Cancer Research Center Box 19024, 1100 Fairview Ave N Seattle, Wa 98109 Timing: Fiscal Year 2003; Project Start 01-MAR-2003; Project End 29-FEB-2008

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Summary: (provided by applicant): The Bio-Rad galactomannan enzyme immunoassay (GM EIA) will soon be submitted to the FDA for approval as an aid to diagnose aspergillosis, a frequent cause of infectious death in immunosuppressed patients. Our preliminary studies suggest that the assay may also be used as a screening test to enable early diagnoses; however, the optimal cut-offs for positivity have not been determined. Defining cut-offs to optimize performance is critical for patients who have different manifestations of infection (endobronchial vs. invasive), such as in solid organ transplant recipients, and in children, who appear to have frequent false-positive results. The studies proposed in this project will define parameters to use the GM EIA in multiple different patient populations, using clinical samples obtained from a large ongoing FHCRC longitudinal protocol in adult allogeneic hematopoietic stem cell transplant (HSCT) recipients, and samples obtained from multicenter trials sponsored by the NIH. Aim 1 will define parameters for use of the GM EIA as an early diagnostic test for aspergillosis in adult allogeneic HSCT patients. Studies will be performed to determine the lower limit of GM detection, identify clinical factors that impact levels of circulating GM, and to determine the role of GM EIA applied to non-blood fluids (bronchoalveolar lavage fluid and urine). Aim 2 will define appropriate cut-offs for positivity and characterize performance of the GM EIA as a diagnostic assay for aspergillosis in high-risk solid organ transplant recipients. To do this, longitudinal sample collection will be performed in a protocol conducted as a companion to an ongoing CDC-sponsored multicenter surveillance study. Aim 3 will define parameters for use of the GM EIA as an early diagnostic test for aspergillosis in neutropenic children. To determine the appropriate cut-offs for positivity in children, GM EIAs will be performed on serial sera obtained from children at high risk for aspergillosis after treatment with induction chemotherapy for AML, and after cord blood transplant. Companion protocols will be performed to collect sera as part of ongoing multicenter studies performed by the Children' s Oncology Group and the NHLBI Cord Blood Transplantation Study. Studies will be performed to determine if false-positivity of the GM EIA in children corresponds with gut translocation of GM during periods of mucositis, by measuring surrogate markers for GI integrity in a case-control study. This project is enabled by the cooperative activities of FHCRC investigators, Bio-Rad Laboratories, and several multicenter networks supported by the CDC, NIAID, and NHLBI. Website: http://crisp.cit.nih.gov/crisp/Crisp_Query.Generate_Screen •

Project Title: CASPASE INHIBITION OF APOPTOSIS, INFANT CARDIAC SURGERY Principal Investigator & Institution: Mcgowan, Francis X.; Associate Professor; Children's Hospital (Boston) Boston, Ma 021155737 Timing: Fiscal Year 2002; Project Start 01-JAN-2001; Project End 31-DEC-2005 Summary: (Verbatim from Applicant's Abstract): A major limitation to successful outcome of the repair of congenital heart lesions is the development of ventricular dysfunction. While the etiology is undoubtedly multifactorial, evidence suggests that it in large part may be due to myocyte loss resulting from chronic cyanosis, prolonged exposure to abnormal hemodynamic loads, and one or more episodes of ischemiareperfusion required for cardiac surgery. Death of myocytes can occur by either necrosis or apoptosis. In contrast to necrosis, apoptosis is the orderlv disassemblv of the cell by specific enzymatic pathways that are triggered by a wide variety of genetic, environmental and toxic stimuli. Recently, human and animal studies have shown that hypoxia, ischemia-reperfusion, abnormal mechanical loading, and inflammation can

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cause significant cardiomyocyte apoptosis. This occurs during myocardial ischemia, infarction, hypertrophy, and heart failure. The role of apoptosis in infants undergoing cardiac surgery is not known. Based upon this information and preliminary data from our laboratory, we believe that myocyte apoptosis is a significant problem in infants with normal and hypertrophied myocardium subjected to surgical ischemiareperfusion. This loss of myocytes will be particularly injurious to the infant myocardium because of the loads imposed by future growth and residual hemodynamic abnormalities. Because the pathways triggering apoptosis in this setting are multiple, we have chosen to focus on the role of the caspase enzymes. Caspases are the focal point of propagation and execution of apoptosis, and are directly responsible for the proteolytic cleavage of specific proteins required for the process to occur. Experiments in Aim I will be the first to l)define which caspases are expressed, activated, and what key intracellular proteins are thereby cleaved in normal and hypertrophied myocardium exposed to surgical ischemia-repercusion, 2)quantify the amount of apoptosis that occurs in this setting, and 3)determine the effects of specific caspase inhibition on these events. Using a novel working heart transplant model with normal and hypertrophied infant hearts, Aim II will answer a question of critical importance, namely what is the effect of inhibition of caspases and apoptosis on long-term myocardial inflammation, fibrosis, and recovery of function? These experiments will be the first to study the beneficial versus harmful roles of apoptosis in myocardial ischemia-reperfusion injury. Overall, these studies will provide valuable new insights into therapeutic targets and strategies to preserve myocardial function in these patients. The results are also likely to be applicable to patients with ischemia, myocardial infarction, and heart failure. Website: http://crisp.cit.nih.gov/crisp/Crisp_Query.Generate_Screen •

Project Title: CCR2 AND CCR5--ATHEROSCLEROSIS AND CONTROL OF EXPRESSION Principal Investigator & Institution: Charo, Israel F.; Professor of Medicine; J. David Gladstone Institutes 365 Vermont St San Francisco, Ca 94103 Timing: Fiscal Year 2002; Project Start 15-JUL-1994; Project End 30-JUN-2003 Summary: (Adapted from the application) The overall goal of this proposal is to determine the role of chemokine receptors in vascular disease. Chemokines (chemotatic cytokines) specifically attract leukocytes by activating G-protein-coupled receptors. The investigators have focused their efforts on two of these receptors, CCR2 and CCR5, which were cloned in this laboratory and which are the major chemokine receptors on monocytes. During the first funding period, the investigators examined the structure/activity relationships of these two receptors with regard to ligand binding and signaling. The work proposed in the current application will extend these in vitro studies to in vivo models, taking advantage of our recent creation of a CCR2 knockout mouse. The first goal of the proposal is to determine the role of CCR2 in two forms of vascular disease: atherosclerosis and the accelerated arteriosclerosis of allogeneic cardiac transplants. The investigators will cross the CCR2-/- mice with apoE-/- mice and perform detailed atherosclerosis studies. The investigators will also perform heterotopic transplants of allogeneic hearts into the CCR2-/- mice and determine whether CCR2 plays a role in chronic myocardial rejection and transplant arteriosclerosis. The second goal is creating CCR2/CCR5 double-knockout mice. The investigators will selectively delete these receptors and simultaneously "knock in" lacZ under the control of the CCR2 promoter and green fluorescent protein (GFP) under the control of the CCR5 promoter. This approach will generate chemokine receptor knockout animals, as well as provide a sensitive means for detecting the endogenous in

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vivo expression of CCR2 and CCR5. Differential regulation of chemokine receptors clustered on chromosome 3 (3p21.3-24) may provide specificity in inflammation and immunity. The third goal is to determine the tissue-specific expression and transcriptional regulation if selected CC receptors. The investigators will use the hemizygous CCR2/CCR5 double-knockout mice (CCR2+/LacZ, CCR5=/GfP), as well as transgenic mice created with large fragments of human genomic DNA, to follow the expression of these two receptors in models of human disease. the experiments proposed in this grant will utilize novel and complementary approaches to provide the first detailed information on the role of chemokines and chemokine receptors in vascular disease. Website: http://crisp.cit.nih.gov/crisp/Crisp_Query.Generate_Screen •

Project Title: CD28/B7 COSTIMULATION BLOCKADE-RESISTANT GRAFT REJECTION Principal Investigator & Institution: Hancock, Wayne W.; Professor; Children's Hospital of Philadelphia 34Th St and Civic Ctr Blvd Philadelphia, Pa 19104 Timing: Fiscal Year 2003; Project Start 15-FEB-2003; Project End 31-JAN-2008 Summary: (provided by applicant): Failure to stem the incidence of chronic rejection continues to diminish the long-term benefits of transplantation. Experimental data suggest the importance of tolerance induction as a means to prevent chronic rejection and minimize drug toxicity, and blockade of CD28/B7 and/or CD154/CD40 can markedly prolong allograft survival, in some cases leading to permanent engraftment. However, costimulation blockade-resistant allograft rejection can still occur. This application is based around recently recognized CD28 and B7 homologs whose ligands are broadly expressed in peripheral tissues, and which likely regulate effector T and B cell responses. We will study the roles of ICOS/B7RP-1 and PD-1/PD-L1/PD-L2 in host alloresponses using murine models of cardiac and islet allograft rejection, thereby allowing consideration of rejection in primarily revascularized vs. non-revascularized grafts, as well as validation of heterotopic cardiac graft data in the more stringent, lifesupporting islet allograft system. Aim 1 will determine the mechanisms by which the ICOS/B7RP-1 costimulatory pathway can regulate T and B cells responses in allograft recipients in vivo, such that targeting of this interaction can diminish chronic rejection and promote tolerance induction. We will dissect the contributions of ICOS and B7RP-1 to T and B cell responses in wild-type as well as CD28- and CD154-independent responses. We anticipate these studies will provide key mechanistic insights into the importance of ICOS/B7RP-1 in ongoing host alloresponses, and how targeting of this pathway can best promote allograft tolerance. Aim 2 hypothesizes that tissue-specific immune responses are regulated by the PD-1/PD-L1/PD-L2 pathway, and we propose to analyze the extent to which manipulation of this pathway can facilitate long-term allograft survival. Our preliminary data show that stimulation of a negative signal through ligation of PD-1 can dampen host alloresponses, including those underlying costimulation blockade-resistant allograft rejection. We will expand these studies to dissect how interactions of PD-1 with its ligands can be promoted to achieve therapeutic effects in allograft recipients. Success in this work would provide a rationale for testing in non-human primates, and may ultimately improve the management and long-term results seen in patients undergoing organ transplantation or receiving islet allografts by promoting graft tolerance and decreasing the incidence of chronic rejection. Website: http://crisp.cit.nih.gov/crisp/Crisp_Query.Generate_Screen

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Project Title: CD4 T CELL DEPENDENT ACUTE CARDIAC ALLOGRAFT REJECTION Principal Investigator & Institution: Pietra, Biagio A.; Pediatrics; University of Colorado Hlth Sciences Ctr P.O. Box 6508, Grants and Contracts Aurora, Co 800450508 Timing: Fiscal Year 2002; Project Start 01-SEP-2001; Project End 31-AUG-2005 Summary: Numerous studies indicate that CD4 T cells are required for acute cardiac allograft rejection. However, the precise role for CD4 T cells in this response has remained ambiguous due to the multi-potential properties of this T cell subpopulation. We have recently demonstrated the capacity of CD4 T cells to serve as direct effector cells of cardiac allograft rejection. CD4 T cells are both necessary and sufficient for acute graft rejection as indicated by adoptive transfer experiments in immune-deficient SCID and rag-/- recipients. Acute CD4 T cell-mediated rejection requires MHC class II expression by the allograft, implicating the importance of direct graft recognition in this response. While CD4 T cells can serve as effector cells for primary acute cardiac allograft rejection via direct donor recognition, they can also serve as helper cells via the indirect response leading to the function of other graft-reactive lymphoid populations. The difficulty in examining the relative contribution of these CD4-dependent pathways to acute allograft rejection is that these responses normally occur simultaneously. In the adoptive transfer model systems proposed, the consequence of direct (donor MHCrestricted) and indirect (host MHC-restricted) CD4 reactivity can be studied independently. Thus, the overall goals of this proposal are to: (1) Clarify the nature of acute CD4-mediated cardiac allograft rejection via direct donor recognition, and (2) Clarify the pathway of 'indirect' CD4 reactivity that results in help for other graftreactive CD8 T cells and/or B cells. These general goals will be examined through the following specific aims: I) Define the recognition and costimulatory requirement(s) of direct CD4-dependent cardiac allograft rejection. This aim will test the novel hypothesis that antigen recognition and costimulation can be delivered by different APCs in vivo. II) Determine the effector mechanism(s) of CD4-dependent direct cardiac allograft rejection. This aim will test the hypothesis that direct, CD4-mediated rejection is cytokine-dependent in vivo. III) Determine the nature of indirect CD4 T cell 'help' for cardiac allograft rejection. This aim will test the hypothesis that indirect CD4 T cells can provide 'unlinked' T cell help for graft reactive CD8 T cells. The information obtained will be useful in understanding the basic immune mechanisms of human cardiac transplantation. Website: http://crisp.cit.nih.gov/crisp/Crisp_Query.Generate_Screen

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Project Title: CD40 COSTIMULATION AND TRANSPLANTATION Principal Investigator & Institution: Perkins, David; Brigham and Women's Hospital 75 Francis Street Boston, Ma 02115 Timing: Fiscal Year 2002; Project Start 01-JAN-1999; Project End 31-DEC-2003 Summary: (adapted from applicant's abstract) Following transplantation, acute rejection is recognized as the most frequent serious complication and the best predictor of chronic rejection, a major cause of long term graft loss. T cells are essential for initiating and maintaining acute rejection. Early intervention in transplant rejection necessitates understanding the mechanisms of T cell activation, as related to allograft survival. The principal investigator and others have found that blockade of CD40 signals prolongs graft survival. The goal of this proposal is to determine which CD40 regulated functions mediate graft rejection. CD40 signals are transduced by both NF-kB-dependent and independent mechanisms. The PI has found that in vivo inhibition of NF-kB activation

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with a dominant negative transgene or by deletion of c-Rel prolongs allograft survival. Thus, one focus will be on the role of CD40-regulated actions that are NF-kB-dependent. The investigators propose the hypothesis that blockade of the CD40/CD40L costimulatory pathway prolongs allograft survival by NF-kB-dependent mechanisms. To test this hypothesis, they will employ an adoptive transfer model of cardiac transplantation using double transgenic lines that express the DO11 TCR transgene, which is cross-reactive with I-Ab, plus null alleles of either CD40, CD40L, c-Rel, or IkBa (DN), a dominant negative inhibitor of NF-kB. Transfer of cells from these animals into Balb/c recipients of C57Bl6 cardiac grafts will provide a means to examine in vivo and in vitro the molecular mechanisms governing CD40/CD40L costimulatory effects. Aim 1 will determine the role of CD40 ligand signals on T cell activation, proliferation, unresponsiveness, and cytokine secretion. Aim 2 will determine the cellular mechanisms by which CD40 expressed on T cells regulates allograft rejection by mechanisms of activation and apoptosis involving FasL and TNF-a signals. Aim 3 will investigate the molecular mechanisms by which activation of NFkB controls allograft survival. Website: http://crisp.cit.nih.gov/crisp/Crisp_Query.Generate_Screen •

Project Title: CELLULAR BASIS OF CMV ACCELERATED VASCULOPATHY Principal Investigator & Institution: Nelson, Jay A.; Director & Professor; Molecular Microbiology and Immunology; Oregon Health & Science University Portland, or 972393098 Timing: Fiscal Year 2002; Project Start 30-SEP-2002; Project End 31-AUG-2006 Summary: (provided by applicant): The long-term goal of this project is to determine the role of viral pathogens in the development of vascular diseases such as atherosclerosis, restenosis, and transplant vascular sclerosis (TVS). All of these diseases are the result of either mechanical or immune related injury followed by inflammation and subsequent smooth muscle cell (SMC) proliferation and/or migration from the vessel media to the intima, which culminates in vessel narrowing. Clinical studies have directly associated human cytomegalovirus (HCMV) with the acceleration of TVS and restenosis as well as atherosclerosis. However, the mechanism(s) involved in the acceleration of vascular disease by HCMV is unknown. Studies by our group and others have implicated endothelial cells (EC), macrophages (MDM) and SMC as potential reservoirs of the virus in the host. Unfortunately, an animal model for HCMV is unavailable. However, mouse cytomegalovirus (MCMV) provides an ideal system to study mechanisms of pathogenesis and cellular tropism in the mouse model. Recently, we have developed a mouse heart transplantation model of TVS, which exhibits all of the hallmarks of human disease. We have also shown that CMV accelerates the progression and severity of TVS. Therefore, in this project we will utilize the mouse TVS model in combination with MCMV to assess the role of viral infection of MDM and EC on the acceleration of disease. In the first specific aim, we will utilize MCMV EC and MDM tropic mutants, which inhibit growth of virus in these cell types to assess the contribution of viral infection of these cells in the acceleration of TVS. In the second specific aim, we will utilize mice which specifically express Cre recombinase in EC and MDM in combination with recombinant MCMV that contain Lox sites which inactivate the virus in the presence of Cre enzyme to assess the role of MCMV replication in MDM and EC in the acceleration of TVS. In the last specific aim, we will examine viral mechanisms which accelerate TVS through ablation of MCMV genes which mediate inflammatory events. Website: http://crisp.cit.nih.gov/crisp/Crisp_Query.Generate_Screen

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Project Title: CELLULAR MECHANISMS OF PTLD IN TRANSPLANT RECIPIENTS Principal Investigator & Institution: Martinez, Olivia M.; Associate Professor; Surgery; Stanford University Stanford, Ca 94305 Timing: Fiscal Year 2002; Project Start 01-MAY-1997; Project End 19-SEP-2003 Description (provided by applicant): Post-transplant lymphoproliferative disease (PTLD) is a morphologically complex disorder that ranges from benign B cell hyperplasia to malignant lymphoma. Epstein-Barr virus (EBV) B cell lymphomas are the hallmark of PTLD and are associated with significant morbidity and mortality. During the previous funding period we identified specific signaling pathways that confer a survival advantage to EBV-infected B cells despite significant frequencies of EBVspecific CD8+ T cells in the circulation of transplant recipients. We also established that the immunosuppressive sirolimus (RAPA) can directly inhibit the growth of EBVinfected B cells. The objective of this research is to defme the immune alterations that contribute to the autonomous growth of EBV-associated B cell lymphomas. To accomplish this objective we propose four Specific Aims. In Specific Aim 1 we will determine the requirement for IL- 10 and its associated Jak/STAT signal transduction pathway in sustaining the growth of EBV-infected B cells. Dominant negative (DN) forms of the 1L-lO receptor (IL-1OR), STAT1 and STAT3 will be transduced into EBVinfected B cells using a lentivirus-based retroviral transduction system to evaluate the effect on cell growth. A SCID mouse model of EBV+ B cell lymphoma will be used to test the effect of blockade of IL-lO on tumor growth. Specific Aim 2 will examine the mechanism by which EBV-infected B cells are resistant to death receptor-induced apoptosis. The proximal events in the Fas and TRAIL-DR4/DR5 cell death pathways will be characterized by two-dimensional gel electrophoresis and DNA microarray. The role of the decoy receptors DcR1 and DcR2 in resistance to TRAIL cytotoxicity will be examined. The contribution of the EBV latent genes LMP1 and EBNA2 to resistance to apoptosis will also be determined. In Specific Aim 3 MHC/peptide tetramers containing immunodominant epitopes of EBV antigens will be used to identify EBV-specific CD8+ T cells in transplant recipients and the functional properties of these T cells will then be assessed. The effects of immunosuppression on the generation of functional EBVspecific CD8+ T cells will be determined in the SCID/EBV B cell lymphoma model. Aim 4 will determine the mechanism by which RAPA inhibits growth of EBV-infected B cells with specific focus on apoptosis, cell cycle proteins and the JakISTAT pathway. Elucidation of the immune mechanisms involved in PTLD will provide novel opportunities for treatment of this serious disease. Website: http://crisp.cit.nih.gov/crisp/Crisp_Query.Generate_Screen

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Project Title: COMPARATIVE APPROACH TO GENOMICS OF COMPLEX TRAITS Principal Investigator & Institution: Goldschmidt-Clermont, Pascal J.; Professor and Chair; Medicine; Duke University Durham, Nc 27706 Timing: Fiscal Year 2002; Project Start 30-SEP-2002; Project End 31-AUG-2007 Summary: (provided by applicant) The determinants of genetic susceptibility for most common traits are complex, likely to involve contributions from multiple gene variants. These variations in gene function that affect critical phenotypes can represent amino acid replacements as well as extragenic differences that might affect expression levels; in most instances, these are single nucleotide polymorphisms (SNPs). Although one would like to assay for these gene variants in a completely unbiased fashion, ultimately measuring the contribution of every variant of every gene, this is obviously impractical at this point in time. An alternative strategy is to identify those genes most likely to

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make contributions to disease variation, identify the variations within this group of genes, and then conduct association studies to link gene variants with disease phenotype. Using cardiovascular disease as a model system, this proposal describes a multi-dimensional approach to this overall problem. In particular, we will use multiple methods for the identification of candidate genes most likely to make contributions to disease variation within populations of patients. This work will take advantage of three unique clinical resources here at Duke. First, we have begun the collection of a large series of aorta samples from heart transplant donors as a source of vascular tissue for gene expression analysis. These samples are unique in the volume of the samples (hundreds) as well as the range of phenotype: early stages of atherosclerosis to advanced forms of the disease. As such, it provides an opportunity to match gene expression profiles with the development of disease in a very unique way. This will be the focus of work in Component 1 as well as statistical efforts in Component 5. Second, a large study of the genetics of early onset cardiovascular disease, representing a collaboration between Duke investigators and GlaxoSmith-Kline, offers the opportunity to identify loci that are linked with the development of disease. This provides a mechanism for the identification of additional candidate genes without any bias whatsoever, including whether the gene actually functions within cardiovascular tissue or not. This represents the focus of Component 2, and bioinformatic efforts in Component 6. The combined efforts of Component I and 2, taking different approaches to the identification of candidate genes, will then be the source of substrate to discover SNPs within this group of genes (Component 3). Much of this work will take advantage of existing information regarding SNPs as well as other major studies directed at cardiovascular disease. But, it will also necessitate efforts within this component to identify as exhaustively as possible those sequence variants that can then be the subject for assays in clinical populations. Third, and possibly the most important asset of this program, is the Duke Cardiovascular Database, an effort initiated some thirty years ago at Duke to follow the clinical course of every cardiovascular disease patient. As such, we now have access to over 40,000 patients who are being followed on a regular basis, creating a clinical dataset that is unmatched. This clinical dataset provides a completely unique resource for this study, both from the quantity as well as the quality of patient clinical data to allow the validation of candidate gene variants with disease variation. Thus, the SNPs identified in Component 3 will go into an expansive genotyping program (Component 4), to bring these candidate genes to a point of validation. A major challenge in an undertaking of such magnitude will be the statistical power to find associations in complex situations. Component 5, will develop the methodologies for understanding the complex gene expression datasets, will also develop the statistical approaches to the analysis of the complex genotyping studies. The program will also enhance and integrate with existing and developing educational programs in bioinformatics and genome technology at Duke (Component 6). This synergy will be of clear benefit to the program, bringing in talented investigators from multiple disciplines in each area critical for the program. Hence, our project will advance the frontiers of genome sciences and technology in the field of common traits. The culmination of our program will provide essential tools to clinicians to improve risk stratification of patients and to design novel preventive and therapeutic strategies. Website: http://crisp.cit.nih.gov/crisp/Crisp_Query.Generate_Screen •

Project Title: CORE--CLINICAL AND PATHOLOGY Principal Investigator & Institution: Rodriguez, Rene E.; Johns Hopkins University 3400 N Charles St Baltimore, Md 21218 Timing: Fiscal Year 2003; Project Start 01-APR-2003; Project End 31-MAR-2008

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Summary: (provided by applicant) The Clinical/Pathology Core will continue to coordinate the collection of tissue and blood samples at the time of transplantation and at the time the allograft is biopsied. Tissues from the explanted hearts and from selected endomyocardial biopsies will be collected. Blood/plasma samples will be collected from donor, recipient, blood bank, and from the spouse of the recipient at the time of transplantation. In addition, this core will act as the repository for all the relevant clinical data in support of these tissue samples. This core will examine the collected tissue and blood samples using general histology, routine immunohistochemistry and specialized coagulation assays in support of individual projects. Finally, this core will provide non-routine noninvasive analyses. Cardiac surgeons at Johns Hopkins have transplanted 337 hearts into human recipients during the last 18 years (to 8/31/01) and the demographics of these recipients are: by gender-93 female, and 244 male; by race- 39 African American, 291 Caucasian, and 7 other; and by age-29 children and 308 adults. During the current period of this program project 86 hearts were successfully transplanted (by gender-29 female, and 57 male; by race-23 African American, 57 Caucasian, and 6 other; and by age-4 children and 82 adults). After transplant, surveillance endomyocardial biopsies are performed every 10 days for the first month, every 14 days for second month, every month for months 3 to 6, and every 4 to 6 months, thereafter. Additional endomyocardial biopsies are performed when the symptoms dictate. 180 heart transplant patients were followed during the most recent year (9/1/00-8/31-01) and 600 endomyocardial biopsies were performed. Website: http://crisp.cit.nih.gov/crisp/Crisp_Query.Generate_Screen •

Project Title: CORE--HISTOPATHOLOGY Principal Investigator & Institution: Sedmak, Daniel D.; Professor and Chair; Ohio State University 1960 Kenny Road Columbus, Oh 43210 Timing: Fiscal Year 2002; Project Start 01-SEP-2002; Project End 31-AUG-2003 Summary: Chronic allograft rejection is the leading cause of renal and cardiac allograft failure. The Long term goal of this core is to assist investigators in acquiring the experimental data necessary for the successful investigation of this disease process. In this program project human cardiac biopsies will be extensively utilized, as well as murine cardiac grafts, for the investigation of chronic rejection; however, meaningful studies with model will require the use of standardized tissue sections, special stains, and quantitative morphometric measurements. Therefore, the short term goals of the Histopathology core are to provide a centralized and standardized histology, immunohistochemistry, and automated morphometric analysis service for all projects. As a central core service it will guarantee a high level of uniformity, consistency and quality that will facilitate comparison of experimental results between the three program projects. The Specific Aims are to (1) provide a central histopathology laboratory for all projects, (ii) provide a central immunohistochemistry laboratory for the detection of disease-related antigens in frozen or formalin-fixed tissues, (iii) provide an automated image analysis and morphometrics service that will provide consistent and uniform measurements of transplant vascular sclerosis and myocardial fibrosis in murine heterotopic heart transplants and human explanted heart autopsy specimens, and (IV) provide a laser capture microdissection (LCM) service that will provide morphometric-like cell populations from thin sections of formalin fixed paraffinembedded or frozen tissues of both animal and human tissues for molecular analysis. The core will be located in The Ohio State University Medical Center and utilize the preexisting Department of Pathology laboratories. Website: http://crisp.cit.nih.gov/crisp/Crisp_Query.Generate_Screen

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Project Title: CORE--HUMAN CARDIAC TISSUE REPOSITORY Principal Investigator & Institution: Rodriguez, E Rene.; Yale University 47 College Street, Suite 203 New Haven, Ct 065208047 Timing: Fiscal Year 2002; Project Start 01-SEP-2002; Project End 31-AUG-2003 Summary: Human Cardiac Tissue Repository Core. To study the immunopathogenesis of human cardiac allograft arteriosclerosis (GA), the Human Cardiovascular Tissue Repository will continue to build on the highly successful existing tissue bank established at Hopkins. The functions of the core will be: 1. To banked fresh-frozen tissues include sections of myocardium and coronary arteries. The number of hears from patients undergoing a re-transplantation have steadily been in the range of 5-15% of all hearts transplanted (average 30 hearts per year) at Hopkins during the last 10 years. The infrastructure in place for this core allows for procurement of human hearts at the time of surgery. Cardiac tissues are triaged and processed immediately as needed by the different projects in this proposal (e.e. freezing, cell culture, organ culture) by a cardiac pathologist as part of the evaluation of the specimen. In addition to the fresh and frozen tissue repository, there is formalin-fixed paraffin- embedded tissue from human heart transplant recipients, which currently includes over 6,000 heart biopsies, 54 autopsies and 223 explanted hearts, including 24 explanted from heart transplant recipients who were re- transplanted because of allograft vasculopathy in their first grafts. 2. Another function of this core be to provide clinical data striped from any identifies to individual investigators. These database is supported by departmental funds and are provided free to the Core. 3. Comprehensive pathologic examination of the tissues will be performed with advanced pathologic techniques in our facilities at Hopkins Molecular Pathology, tissues will be performed with advanced pathologic techniques in our facilities at Hopkins Molecular Pathology, Research Immunohistochemistry, and Research Histology laboratories. 4. Cardiac allograft arteriosclerosis lesions will be microdissected and analyzed with an array of ProteinChips/TM to identify protein expression alterations in the allograft important mechanism in the pathogenesis of cardiac allograft arteriosclerosis. Accordingly, the proteomics core will focus on the role of IFN-gamma and the molecules that both, regulate IFN-gamma and are regulated by IFN-gamma, leading to proliferation of TH1 cells. The proteomics core will correlate expression of molecules identified in projects 1, 2 and 3 taking advantage of phage-peptide-display libraries and candidate gene sequences identified in core E (RNA microarrays). Core D will microdissect cells from human coronary arteries. Microdissection will allow the comparison of the proliferative cell component present in the intima of GA vessels with musculopathy and smooth muscle cells from the media of transplant arteries and controls. The power of the proteomics analysis with the ProteinChipTM technology is that femtomolar amounts of proteins can be identified, thus requiring only a few hundred to a few thousand cells from human arteries to obtain protein expression information. The integration of this core with the projects in this proposal will provide scientific basis to develop effective approaches to early diagnosis of GA and provide information of possible targets for early therapeutic intervention, which is crucial to lengthen the longevity of the allograft. Website: http://crisp.cit.nih.gov/crisp/Crisp_Query.Generate_Screen

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Project Title: RECIPIENTS

COSTIMULATORY

PATHWAYS

IN

SENSITIZED

GRAFT

Principal Investigator & Institution: Kupiec-Weglinsky, Jerzy W.; Professor; Surgery; University of California Los Angeles 10920 Wilshire Blvd., Suite 1200 Los Angeles, Ca 90024

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Timing: Fiscal Year 2002; Project Start 01-APR-1988; Project End 31-MAR-2007 Summary: (provided by applicant) Transplant patients sensitized to allo-Ag may undergo "accelerated" rejection (AccR), which combines cell and humoral immune mechanisms. We have developed a model of cardiac allograft rejection in skin sensitized mice (B/c- B6; rejection in