Evaluation of inflammatory effects of airborne endotoxin emitted from composting sources

Because of the lack of effective methodology, the biological effects of environmental endotoxin have not been assessed. Here we have collected and measured airborne endotoxin at different locations around composting sites. Increased endotoxin concentrations were observed close to composting activities and also at nearby boundary areas. Analysis of proinflammatory effects of the environmental endotoxin on interleukin (IL)-8 and IL-6 release from human D562 pharyngeal epithelial and MM6 monocytic cell cultures showed an association between endotoxin level and cytokine induction. The cytokine-inducing effect of bioaerosol extracts was inhibited by polymyxin B, indicating that endotoxin was the cause of cytokine responses we found. The environmental endotoxin was also more active for stimulating cytokines in airway epithelial cells than commercially purified Escherichia coli endotoxin. Our results suggest that these in vitro inflammatory cell models may contribute to the assessment of health impacts of environmental endotoxin.

When is a soil remediated? Comparison of biopiled and windrowed soils contaminated with bunker-fuel in a full-scale trial

A six month field scale study was carried out to compare windrow turning and biopile techniques for the remediation of soil contaminated with bunker C fuel oil. End-point clean-up targets were defined by human risk assessment and ecotoxicological hazard assessment approaches. Replicate windrows and biopiles were amended with either nutrients and inocula, nutrients alone or no amendment. In addition to fractionated hydrocarbon analysis, culturable microbial characterisation and soil ecotoxicological assays were performed. This particular soil, heavy in texture and historically contaminated with bunker fuel was more effectively remediated by windrowing, but coarser textures may be more amendable to biopiling. This trial reveals the benefit of developing risk and hazard based approaches in defining end-point bioremediation of heavy hydrocarbons when engineered biopile or windrow are proposed as treatment option.

Removal of steroid estrogens in carbonaceous and nitrifying activated sludge processes

A carbonaceous (heterotrophic) activated sludge process (ASP), nitrifying ASP and a nitrifying/denitrifying ASP have been studied to examine the role of process type in steroid estrogen removal. Biodegradation efficiencies for total steroid estrogens (Sigma(EST)) of 80 and 91% were recorded for the nitrifying/denitrifying ASP and nitrifying ASP respectively. Total estrogen biodegradation (Sigma(EST)) was only 51% at the carbonaceous ASP, however, the extent of biodegradation in the absence of nitrification clearly indicates the important role of heterotrophs in steroid estrogen removal. The low removal efficiency did not correlate with biomass activity for which the ASP(carbonaceous) recorded 80 microg kg(-1) biomass d(-1) compared to 61 and 15 microg kg(-1) biomass d(-1) at the ASP(nitrifying) and ASP(nitrifying/denitrifying) respectively. This finding was explained by a moderate correlation (r(2)=0.55) between total estrogen loading (Sigma(EST) mgm(-3)d(-1)) and biomass activity (microg Sigma(EST) degraded kg(-1) d(-1)) and has established the impact of loading on steroid estrogen removal at full-scale. At higher solids retention time (SRT), steroid estrogen biodegradation of>80% was observed, as has previously been reported. It is postulated that hydraulic retention time (HRT) is as important as SRT as this governs both reaction time and loading. This observation is based on the high specific estrogen activity determined at the ASP(carbonaceous) plant, the significance of estrogen loading and the positive linear correlation between SRT and HRT.

An international review of the challenges associated with securing 'buy-in' for water safety plans within providers of drinking water supplies

Since publication of the 3rd Edition of the World Health Organisation (WHO) Drinking Water Quality guidelines, global adoption of water safety plans (WSPs) has been gathering momentum. Most guidance lists managerial commitment and 'buy-in' as critical to the success of WSP implementation; yet the detail on how to generate it is lacking. This commentary discusses aspects of managerial commitment to WSPs. We argue that the public health motivator should be clearer and a paramount objective and not lost among other, albeit legitimate, drivers such as political or regulatory pressures and financial efficiency.

Endotoxin emissions from commercial composting activities

This paper describes an exploratory study of endotoxin emissions and dispersal from a commercial composting facility. Replicated samples of air were taken by filtration at different locations around the facility on 10 occasions. Measurements were made of endotoxin and associated culturable microorganisms. The inflammatory response of cell cultures exposed to extracts from the filters was measured. Endotoxin was detected in elevated concentrations close to composting activities. A secondary peak, of lesser magnitude than the peak at source was detected at 100-150 m downwind of the site boundary. Unexpectedly high concentrations of endotoxin were measured at the most distant downwind sampling point. Extracted endotoxin was found to stimulate human monocytes and a human lung epithelial cell line to produce significant amounts of pro-inflammatory cytokines. On a weight basis, endotoxin extracted from the composting source has a greater inflammatory cytokine inducing effect than commercial E. coli endotoxin.

Adding omalizumab to the therapy of adolescents with persistent uncontrolled moderate--severe allergic asthma

OBJECTIVE

This study aimed to evaluate the effectiveness of omalizumab among adolescents with moderate-severe allergic asthma inadequately controlled with inhaled corticosteroids.

PATIENTS AND METHODS

Data from patients 12 to 17 years of age were pooled from 5 placebo-controlled registration trials of omalizumab. Impact on asthma control was assessed by need for rescue bursts of oral corticosteroids, lung function, symptom scores, and unscheduled office visits.

RESULTS

In adolescents (n = 146), addition of omalizumab decreased mean number of rescue bursts (0.3 vs 0.9) versus placebo; relative risk 0.47 (95% confidence interval [CI], 0.22-0.99; P = .047). At study conclusion, mean forced expiratory volume in 1 second increased 268 mL (13.8%) in omalizumab-treated subjects versus 98 mL (5.5%) for placebo (least squares mean treatment difference 146 mL [95% CI, 19.4-272.6; P = .024]). Omalizumab significantly improved asthma symptom scores and reduced unscheduled office visits.

CONCLUSION

Omalizumab added to baseline therapy improves measures of asthma control in adolescents with persistent moderate-severe allergic asthma.

Influence of operating parameters on the biodegradation of steroid estrogens and nonylphenolic compounds during biological wastewater treatment processes

This study investigated operational factors influencing the removal of steroid estrogens and nonylphenolic compounds in two sewage treatment works, one a nitrifying/denitrifying activated sludge plant and the other a nitrifying/denitrifying activated sludge plant with phosphorus removal. Removal efficiencies of >90% for steroid estrogens and for longer chain nonylphenol ethoxylates (NP4-12EO) were observed at both works, which had equal sludge ages of 13 days. However, the biological activity in terms of milligrams of estrogen removed per day per tonne of biomass was found to be 50-60% more efficient in the nitrifying/denitrifying activated sludge works compared to the works which additionallyincorporated phosphorusremoval. A temperature reduction of 6 degrees C had no impact on the removal of free estrogens, but removal of the conjugated estrone-3-sulfate was reduced by 20%. The apparent biomass sorption (LogKp) values were greater in the nitrifying/denitrifying works than those in the nitrifying/denitrifying works with phosphorus removal for both steroid estrogens and honylphenolic compounds possibly indicating a different cell surface structure and therefore microbial population. The difference in biological activity (mg tonne(-1) d(-1)) identified in this study, of up to seven times, suggests thatthere is the potential for enhancing the removal of estrogens and nonylphenols if more detailed knowledge of the factors responsible for these differences can be identified and maximized, thus potentially improving the quality of receiving waters.

A role for human reliability analysis (HRA) in preventing drinking water incidents and securing safe drinking water

The prevalence of water quality incidents and disease outbreaks suggests an imperative to analyse and understand the roles of operators and organisations in the water supply system. One means considered in this paper is through human reliability analysis (HRA). We classify the human errors contributing to 62 drinking water accidents occurring in affluent countries from 1974 to 2001; define the lifecycle of these incidents; and adapt Reason's 'Swiss cheese' model for drinking water safety. We discuss the role of HRA in human error reduction and drinking water safety and propose a future research agenda for human error reduction in the water sector.

Wastes as co-fuels: the policy framework for solid recovered fuel (SRF) in Europe, with UK implications

European Union (EU) member states are adopting the mechanical-biological treatment (MBT) of municipal solid waste (MSW) to comply with EU Landfill Directive (LD) targets on landfill diversion. We review the policy framework for MSW-derived solid recovered fuel (SRF), composed of paper, plastic, and textiles, in the energy-intensive industries. A comparatively high calorific value (15-18 MJ/ kg) fuel, SRF has the potential to partially replace fossil fuel in energy-intensive industries, alongside MSW in dedicated combustion facilities. Attempts by the European standards organization (CEN) to classify fuel properties consider net calorific value (CV) and chlorine and mercury content. However, the particle size, moisture content, and fuel composition also require attention and future studies must address these parameters. We critically review the implications of using SRF as a co-fuel in thermal processes. A thermodynamic analysis provides insight into the technical and environmental feasibility of co-combusting SRF in coal-fired power plants and cement kilns. Results indicate the use of SRF as co-fuel can reduce global warming and acidification potential significantly. This policy analysis is of value to waste managers, policy specialists, regulators, and the waste management research community.

Modeling human exposures to air pollution control (APC) residues released from landfills in England and Wales

Human exposures to air pollution control (APC) residues released from 6 landfills were modeled and assessed. Following a qualitative risk characterisation, direct and indirect exposures were quantified. Site-specific air dispersion modeling was conducted for PM(10), PCDDs/PCDFs, Pb, Cd, As and Cr(VI) concentrations at the closest residential points of exposure for 4 landfill sites accepting, in total, 75% w/w of the APC residues disposed of in 2000-2001 (UK). Inhalation risks, assessed by reference to air quality standards at residential exposure points, were assessed as insignificant. Preliminary modeling suggested that indirect exposures from PCDDs/PCDFs at the 95th percentile level for the site where APC deposition rates were highest could potentially exceed the tolerable daily soil intake (TDSI) but this warrants further study given the model limitations. These results offer an initial screen of the significance of potential risks from APC disposal, which is of value in addressing concerns about the uncertainty of potential risks to human health from bulk APC disposal at strategic locations.

Producer responsibility, waste minimisation and the WEEE Directive: case studies in eco-design from the European lighting sector

The EU Directive on Waste Electrical and Electrical Equipment (WEEE) (2002/96/EC), to be implemented in stages from August 2004, attempts to tackle the growing quantity WEEE by making producers responsible for the costs of the collection and recycling of their products at the end of usable life. This is considered to give producers a financial incentive to reduce waste at source through eco-design. This link is, however, under-researched and little is known generally about the effectiveness of extended producer responsibility (EPR) and policies to promote it. This paper presents the findings of an exploratory study to address these important gaps in knowledge. Literature review was used to develop an analytical framework to explain the relationships between the drivers for eco-design and the role of policies to promote EPR. This was applied to eight case studies of firms from the European lighting sector. While quantitative data to confirm the link between EPR and eco-design were difficult to obtain, the case studies showed that EPR has had little effect on product development so far. Within the sector studied, most producers have been able to pass on incremental costs associated with EPR to customers with negligible effects on sales. This reflects perceptions in the lighting sector that, because demand for products is relatively price inelastic and the regulation affects all producers equally, EPR is unlikely to drive eco-design at least in the short run. The cases also showed that choice between individual and centrally provided waste recovery schemes rested on perceptions of relative costs and practicability. It was evident that other drivers, such as bans on hazardous substances, product declarations and supply chain pressures, were often more effective promoters of eco-design. Thus it seems a mix of policy measures is required rather than reliance on economic instruments alone.

Prostate Specific Antigen Isoforms and Human Glandular Kallikrein 2—Which Offers the Best Screening Performance in a Predominantly Black Population?

PURPOSE

Free prostate specific antigen, complexed PSA and human glandular kallikrein 2 have independently been tested against the gold standard of total PSA for prostate cancer screening in largely white populations. With the incidence of prostate cancer much higher in black men, we sought to evaluate these markers simultaneously in a predominantly black population.

MATERIALS AND METHODS

A total of 138 men, of whom 108 were black, underwent ultrasound guided biopsy of the prostate for tPSA levels greater than 2.5 ng/ml or an abnormal digital rectal examination. Sera were drawn before biopsy and analyzed for tPSA, fPSA, cPSA and hK2 concentrations using standard methods (hK2 assay is for research use only, not for use in diagnostic procedures). The areas under the receiver operator characteristic curves were determined for each marker as well as biomarker combinations. Additionally, each parameter's specificity, positive and negative predictive values, and theoretical screening efficiency were assessed at or above the 95% sensitivity level.

RESULTS

A total of 43 (31.1%) men had prostate cancer by biopsy. While the AUC for %fPSA was statistically the highest (0.822, p <0.001), cPSA offered the highest specificity (31.6%) and positive predictive power (31.7%) of any of the tested biomarkers at comparable sensitivity (greater than 95%). The calculated efficiency of cPSA (51.4%) was also higher than the other markers. Nearly 20% of biopsies would be avoided using cPSA vs standard tPSA screening methods.

CONCLUSIONS

Comparing the major PSA isoforms and hK2, cPSA alone appears to offer superior diagnostic discrimination for cancer detection in a predominantly black population.

The ATAC (‘Arimidex’, Tamoxifen, Alone or in Combination) adjuvant breast cancer trial: first results of the endometrial sub-protocol following 2 years of treatment

BACKGROUND

Tamoxifen treatment results in a doubling of the risk of endometrial cancer after 1-2 years of treatment and a quadrupling after 5 years. Anastrozole, a third-generation aromatase inhibitor, with superior efficacy to tamoxifen, may also offer tolerability benefits in terms of effects on the endometrium.

METHODS AND RESULTS

A sub-protocol of the ATAC trial compared the incidence/type of intrauterine changes following treatment with these agents in a subgroup of patients (n = 285) from the main trial. After 2 years anastrozole treatment, endometrial thickness remained </= 5 mm (baseline: 3.0 mm); in patients receiving tamoxifen, endometrial thickness increased by 3.2 mm to 7.0 mm, with a similar trend in the combination group. At baseline, 26/285 patients (9.1%) had endometrial abnormalities, most commonly polyps. After 2 years the number of endometrial abnormalities appeared lower with anastrozole treatment compared with tamoxifen although these differences were not statistically significant (odds ratio: 0.44; 95% confidence interval 0.146, 1.314; P = 0.14). Most abnormalities occurred within the first year of treatment (anastrozole: 4/6; tamoxifen: 7/10; combination: 10/16; total: 21/32). Fewer patients in the anastrozole group (1.4%) required medical intervention (tamoxifen 12.5%; combination 13.6%).

CONCLUSIONS

Fewer endometrial abnormalities occurred during 2 years treatment with anastrozole compared with tamoxifen although statistical significance was not reached in this sub-protocol analysis.

Assessment of municipal waste compost as a daily cover material for odour control at landfill sites

The ability of municipal waste compost as a daily cover material to reduce the odorous emissions associated with landfill surfaces was investigated. Trials were carried out using landfill gas, a certified sulphurous gas mix and ambient air as a control. Odorous gas was passed through portable test column filled with compost at different densities (590 kg/m3 and 740 kg/m3). Gas samples were taken from the inlet, outlet and at varying column depths and examined using a combination of sensory analysis (olfactometry) and a novel analytical method (Transportable Selected Ion Flow Tube--TSIFT). Results for the trials using landfill gas showed a 69% odour reduction (OU/m3) through the column for compost with a bulk density of 590 kg/m3, and a reduction of 97% using compost with a bulk density of 740 kg/m3. TSIFT analysis showed an overall decrease in the concentration of terpenes, and sulphurous compounds in the outlet gas from the column for both bulk densities. No significant trend could be identified for the concentrations at different depths within the column. Results show the ability of compost to reduce landfill odours under differing conditions. The inconclusive data provided by TSIFT analysis may be due to the analysis of compounds that are not contributing to odour, and thus highlights the potential for synergetic effects and the importance of sensory measurement when examining odorous emissions.

The ATAC (‘Arimidex’, Tamoxifen, Alone or in Combination) adjuvant breast cancer trial: baseline endometrial sub-protocol data on the effectiveness of transvaginal ultrasonography and diagnostic hysteroscopy

BACKGROUND

The 'Arimidex', Tamoxifen, Alone or in Combination (ATAC) trial is a randomized, double-blind trial comparing anastrozole ('Arimidex'), alone or in combination with tamoxifen, relative to tamoxifen alone as 5 year adjuvant treatment for post-menopausal women with early breast cancer. Since tamoxifen is associated with endometrial pathology, the ATAC endometrial sub-protocol was initiated to establish the background prevalence of intrauterine pathology, and to assess prospectively the incidence and nature of intrauterine changes following endocrine therapy. Another aim was to provide data from which advice could be generated on the best endometrium screening method for patients receiving tamoxifen.

METHODS

Patients underwent endometrial assessments at entry to the sub-protocol. The baseline investigations comprised transvaginal ultrasound scanning (TVUS), a hysteroscopy and an endometrial biopsy.

RESULTS

A total of 285 gynaecologically asymptomatic women from 31 centres in 10 countries entered the endometrial sub-protocol. The mean uterine volume was 47.7 cm3. The median endometrial thickness overall was 3 mm. Twenty-four histologically confirmed, pathological changes were observed. Twenty-three pathologies were confirmed by TVUS, and 21 were identified by hysteroscopy and confirmed by histopathology. Women with or without intrauterine pathology had median endometrial thickness of 5 and 3 mm respectively.

CONCLUSIONS

The presence of pathology was associated with increased endometrial thickness. The relative sensitivity and specificity of hysteroscopy and endometrial thickness for the diagnosis of endometrial pathology was comparable to other studies. If screening of the endometrium prior to treatment is appropriate, this study supports the use of an endometrial thickness of 3 mm, as assessed by TVUS, as a threshold for needing further investigation. This study demonstrates that if the endometrial thickness is >3 mm, hysteroscopy and biopsy is the optimal method of detecting intrauterine pathology in women with breast cancer who are about to commence endocrine treatment.

The ATAC adjuvant breast cancer trial in postmenopausal women: baseline endometrial subprotocol data

OBJECTIVE

The ATAC (Arimidex, Tamoxifen, Alone or in Combination) trial is a randomised, double-blind trial comparing 'Arimidex' (anastrozole), alone or in combination with tamoxifen, relative to tamoxifen alone as a five year adjuvant treatment for postmenopausal women with early breast cancer. Because tamoxifen is associated with endometrial pathology, the ATAC endometrial subprotocol was initiated to establish the background prevalence of pathology, and to assess prospectively the incidence and nature of intrauterine changes before and following endocrine therapy.

SETTING

International. POPULATION AND STUDY DESIGN: Two hundred and eighty-five women entered the subprotocol: the mean age was 60 years (range 44-80 years); 113 women (40%) had taken hormone replacement therapy prior to randomisation, and 238 women were parous (84%). The age at onset of the menopause was 32-58 years, with the majority becoming menopausal between 46 and 55 years of age. Two hundred and seventy-two women had a hysteroscopy before they commenced trial medication. Hysteroscopy was performed successfully in 265 women. In six women, failure of hysteroscopy at baseline led to withdrawal from the study. Three of the women who withdrew had a pipelle biopsy taken. Therefore, the total number of endometrial biopsies at baseline was 268.

MAIN OUTCOME MEASURES

To assess the demographic characteristics of women entering the endometrial subprotocol and their hysteroscopic and histological findings before commencing trial medication.

RESULTS

At hysteroscopy, there was a diagnosis of endometrial polyps in 34 women (13%), fibroids in 16 women (6%) and one case of suspicious endometrium, which was confirmed as a polyp on histology. Only 21 of the 34 polyps seen hysteroscopically were proven histologically (62% accuracy of hysteroscopy). Final histology found the prevalence of endometrial diagnostic categories as follows: 123 inactive endometrium (46%), 20 benign polyps (7%), 17 secretory endometrium (6%), 7 proliferative endometrium (3%), 3 atypical hyperplasia (2 in a polyp), 1 simple hyperplasia (in a polyp) and 1 fibroid. The remaining women had pipelle samples with insufficient tissue obtained, indicating a normal endometrial cavity.

CONCLUSION

This is the first study of such size in gynaecologically asymptomatic breast cancer patients. This paper describes the findings in individual patients before any trial treatment was given. In this baseline group, 82% (219/268) of women had a normal endometrial cavity; 18% (49/268) had endometrial activity (proliferative or secretory endometrium in 9%) or an intracavity abnormality (hyperplasia, polyps and a fibroid in 9%). In total, 36% of biopsies had insufficient tissue for diagnosis, which in combination with a normal hysteroscopy was classed as normal. The appearance of a polyp hysteroscopically in this group was not proven histologically in approximately 40% of cases. The development of uterine pathology over time in the ATAC study will subsequently be assessed against the findings of this baseline paper.

Complexed PSA performance for prostate cancer detection in an African-American population

OBJECTIVES

Complexed prostate-specific antigen (cPSA) has been shown to improve the differentiation of benign and malignant disease compared with total PSA (tPSA) in studies evaluating predominantly white populations of men. We sought to evaluate the diagnostic performance of cPSA relative to tPSA in a population of African-American men.

METHODS

Consecutive African-American men scheduled for prostate biopsy were enrolled prospectively at the Louisiana State University Medical Center, New Orleans. Serum was collected before the biopsy procedure and tested with the Immuno 1 tPSA and cPSA methods. Receiver operating characteristic curve analysis was performed and the area under the curve was calculated for tPSA and cPSA.

RESULTS

A total of 156 patients were evaluated, 51 (32.7%) of whom were diagnosed with prostate cancer. The median PSA value for men with prostate cancer was 4.96 ng/mL and for those with benign disease was 3.93 ng/mL. The receiver operating characteristic analysis indicated that the area under the curve for cPSA (0.679) was statistically greater than that achieved for tPSA (0.642, P = 0.004). Using cutoff values for cPSA of 2.3 ng/mL and for tPSA of 2.85 ng/mL provided a specificity of 31.4% and 26.7%, respectively, at a sensitivity for prostate cancer detection of 95%. This was not statistically significant (P = 0.18).

CONCLUSIONS

cPSA offers modest improvement in prostate cancer detection compared with tPSA in African-American men, but not at the clinically relevant 95% sensitivity level. Additional work is needed to improve prostate cancer detection in this high-risk cohort of patients.

Adult small intestinal transplantation in England and Wales

BACKGROUND

In 1996 two transplantation centres in the UK were commissioned by the National Specialist Commissioning Advisory Group for England and Wales to assess small intestinal transplantation in adults. The joint experience of the two centres is presented.

METHODS

Patients with irreversible small intestinal failure and complications of parenteral nutrition, and those with abdominal disease requiring extensive visceral resection, were assessed as candidates and where appropriate listed for surgery.

RESULTS

Thirty-six patients were assessed for small intestinal transplantation and, of these, 14 underwent surgery. Twelve patients survived the transplantation procedure. Of these, seven patients were alive at 1 year, five at 3 years and three at 5 years. Three patients remain alive. Patient and graft survival improved with experience; the 1-year survival rate improved in the last 4 years of this experience from 43 to 57 per cent, and the 3-year survival rate from 29 to 43 per cent.

CONCLUSION

Small intestinal transplantation is associated with a high mortality rate but may benefit carefully selected patients in whom conservative management is likely to carry a greater mortality rate.

The GABA(A) receptor complex in the chicken brain: immunocytochemical distribution of alpha 1- and gamma 2-subunits and autoradiographic distribution of BZ1 and BZ2 binding sites

Two antibodies, raised against the rat GABA(A) receptor alpha1- and gamma2-subunits, were used for an immunocytochemical study of the distribution of these proteins in the chicken brain. The immunoreactive bands obtained by Western blotting and the similar labelling distribution found in the rat and chicken brain support the suitability of these antibodies for the labelling of GABA(A) receptors in birds. We found abundant alpha1 and gamma2 immunoreactivity throughout the chicken brain, mainly in the paleostriata and lobus paraolfactorius, dorsal thalamus and some nuclei of the brainstem. The alpha1-subunit was more abundant in the telencephalon, thalamus and cerebellum, while the presence of the gamma2-subunit was stronger in the optic tectum and brainstem. We also report the autoradiographic distribution of the BZ1 and BZ2 benzodiazepine receptor subtypes in the chicken brain using [3H]flunitrazepam. Benzodiazepine binding was unevenly distributed throughout the chicken brain, and the anatomical distribution of the BZ1 and BZ2 subtypes was similar to that described in mammals. The highest binding values were found in the olfactory bulb, paleostriatum primitivum, optic tectum, nucleus mesencephalicus lateralis pars dorsalis and nucleus isthmi pars parvocellularis, the BZ2 subtype being predominant in the paleostriatum primitivum and optic tectum. A general agreement in the distribution of BZ1 and alpha1 immunoreactivity was observed in structures such as the olfactory bulb, paleostriata, lobus parolfactorius and dorsal thalamus, although some discrepancies were observed in areas such as the optic tectum or nucleus isthmi pars parvocellularis, with high BZ1 binding and low or no alpha1 immunolabelling.